Measurement of the anatomical length of the upper limb. Methods for measuring the length of the limbs and the volume of movement in the joints. Methods of computer communications of vertebrate motor segments

Measurement of length and circumference of the limbs.

The length of the limbs is measured by two methods that complement each other: by comparing (using symmetric bone protrusions) and with measuring instruments. The length of the upper limb is measured from the vertex of the acromion to the cylinder radiation bone either or to the end of the III of the finger; the length of the shoulder - from the edge of the acromion to the elbow process or to the lateral brave bone pearly; The length of the forearm is from the elbow process to the breadth of the elbow bone.

The length of the lower limb is determined, measuring the distance from the upper front iliac oce to the medial ankle (Fig. 4); The length of the hip is from a large skeleton of the femoral bone to the articular gap of the knee joint, the length of the shin - from the articular slot of the knee joint to the edge of the lateral ankle.

With pelvic ring fractures With the displacement it is necessary to find out if there is a shortening limb. For this measure the distance from the sword-shaped process to the upper front iliac apartments.

The following types of shortening or lengthening of the limb are distinguished:

1. Anatomical, or true, shortening - is observed in the delay in the growth of the limb, damage to episarry cartilage, displacement of fragments; It is measured by bone protractions of long tubular bones.
2. Apparent, or projection, shortening - due to the vicious facility of the limb due to contracture or ankylosis in the joint (for example, ankylosis in the hip joint in the flexion position creates a projection shortening of the limb compared to healthy, although there is no anatomical shortening of the bone).
3. Relative shortening - occurs when changes in the location of the articious segments (dislocations) and is measured, for example, on the lower limb from the upper front ileal ocelock to the medial ankle in comparison with a healthy foot installed as possible in the same position with the patient. It is necessary that the pelvis is in the correct position and both upper front iliac akstas were located on the same line.
4. Functional shortening - determined by the vertical position of the patient. To do this, under the shortened leg substitute a plate with a height of 1 - 1.5 cm until both upper front iliac axes are at the same level. The compensatory curvature of the spinal column usually disappears, the patient confidently stands on the legs. The height of substituted powder indicates the degree of functional shortening.

Elimination circumference is measured In symmetric places at certain distances from bone identification points. With subsequent measurements of the circumference of the damaged limb, there is an increase in edema, hematomas, an increase in traffic in the joint, muscle atrophy.

Proper and fast diagnosis is the key to successful treatment. An indicative diagnosis is determined by the information that is reported at the scene of the eyewitness when calling "ambulance". The basis for such a diagnosis is the circumstances of injury, the overall condition of the victim and obvious damage that a non-specialist can establish. More accurate information is reported by the traffic police officers of the traffic police, police, health workers. A preliminary diagnosis (doghospital) establishes a doctor of ambulance crew and a polyclinic traumatologist or traumatology. The main thing in this diagnosis is to determine dangerous damage or damage that can give fatal complications. Purposeful

the search for such damage is an important principle of diagnosis in acute injury.

The quality of the preliminary diagnosis depends on the experience and knowledge of the traumatologist. From the accuracy of the preliminary diagnosis, in turn, tactics depend on the focus and the amount of assistance in the pre-hospital stage.

Final diagnosis of surface injury, simple fracture (ankles, bones of forearm, brushes, feet), dislocationinstall, as a rule, in a traumatological paragraph with primary handling using standard radiography.

For final diagnosis of complex injury(fractures of the bones of the leg, hips, shoulder, pelvis, spine, CMT, polytrauma) is required to participate in the examination of the victims of several specialists: a orthopedic traumatologist, a neuropathologist, neurosurgeon, an oculist, a radiologist, etc.

Clarify the nature of damage by modern methods radiation diagnosis - radiography, computed tomography (CT), magnetic resonance imaging (MRI), angiography, radionuclide diagnosis; biomechanical, electrophysiological, biochemical, immunological diagnostic methods. Auxiliary diagnostic means are ultrasonicography, doppler, thermography, re-vazography, polarography and other research methods.

The general view of the patient, its motor activity, mental state immediately oriented the doctor with respect to the severity of damage. Finding out the mechanism of injury and duration of the post-traumatic period determines the tactics of the survey of the victim. With insulated injury, the doctor has the opportunity to familiarize himself with the history: as fell, as he lay, that he felt, could stand independently, etc. Good contact with the victim, who clearly expresses its complaints, greatly facilitates the diagnosis.

With severe polytrame accompanied by a violation of consciousness from the victim, the diagnostic examination is carried out simultaneously with the provision of subsequent assistance, intensive care and treatment. Despite the diversity of combinations of various lesions, in the clinical picture of severe political science, several main traumatic foci can be distinguished, directly threatening the life of the victim.

With multiple injuries, one of the main causes of traumatic shock is blood loss.If the victim fails to quickly establish the cause of low blood pressure, it is necessary, first of all, to think about hidden bleeding, the source of which is most often damage to the spleen and liver (intraperous bleeding), fractures of the pelvis bones (retroperitoneal bleeding), damage to the intercostal arteries at the fracture of the ribs (intrapharmal bleeding), fractures of hips and lower legs (intramaneal bleeding). In victims with an extensive throllery muscle, with acutely developing infection (gas gangrene, peritonitis), the threatening life hypovolemia may be the result of blood accumulation and plasma loss in the field of extensive inflammatory and toxic edema.

Aggravating factor in the development of heavy shock and terminal states is acute respiratory failure(OND). Pronounced gas exchange disorders in the lungs occur with multiple fractures of the ribs (especially in the formation of the "rib valve"), lung bumps, pnene-mo and hemotorex.

For damage to the brainfor the clinical picture, long disturbances of consciousness, respiration, blood circulation are characteristic. The communal symptoms are manifested in the form of extreme deviations from the norm: tachycardia, bradycardia, arterial hypotension (due to the concomitant blood loss). Special multiplicity of clinical forms are characterized by respiratory disorders: from full stop and coarse rhythm disorders to central hyper and hypoventilation with a sharp increase or reduction of respiratory frequency (CH). Terminal lung ventilation disorders in severe cases are associated either with the primary destruction of the brain barrel, or with the secondary squeezing of hematoma or edema. In hyperventilation of central origin, hypoxia with its negative influence on hemodynamics and metabolic processes is rapidly developing. In hypoplation, hazardous heartfelt disorders arise (up to asistolia) due to hypercaps and hypoxhemia. The central respiratory disorders, as a rule, are peripherals associated with the violation of the airway pathways.

In 80% of cases, heavy CMT is the immediate cause of the death of victims are asphyxia. The most severe disorders of the function of the apparatus of external respiration are developing with a combination of CMT with multiple fractures of ribs.

Long, more than a day, loss of consciousness, areflexia, lack of self-breathing, paralytic expansion of pupils, electric "silence" of the brain usually indicate irreversible changes in cerebral cells, about "brain death". The death of the brain may be due to the squeezing of its hematoma or edema. Signs of increasing intracranial pressure: progressive deterioration in the overall state of the affected, deepening of the brain coma, respiratory disorders and hemodynamics, the increase in the rigidity of the muscles of the neck and back, increase the likvorn pressure. In the affected in a state of alcohol intoxication, the signs of the cranial and brain injury may not fit into a typical clinical picture. However, to explain the severity of the state of patients with political polytrauma alcoholic intoxication (poisoning) is a rough error.

Ears of the heartmost often arise in road traffic accidents (accidents) and drops from height, usually combined with damage to the chest, pelvis, limbs, skulls. Clinically, the eyes of the heart are manifested in the form of cardiogenic hypoxirkiirculation syndrome: pain in the heart, anxiety, fear, sensation of suffocation, finger numbness, weakness, confusion of consciousness, earth-gray with a blue skin color, skin moisture, cold sweat. Large veins are swollen, periodically pulsed, possibly the appearance of signs of pulmonary edema. The pulse of weak filling, arrhy-

mia, pronounced tachycardia, small pulse pressure, low blood pressure, high CVD. Detailed information about the presence and nature of heart lesions gives ECG (signs characteristic of myocardial infarction).

In hard victims with political stratum there is always a threat of sudden heart stops.It may be associated with a reflex factor (for example, with vomiting, sucking the mucus from the trachea), with a sharp deterioration of the conditions of cardiac activity (acute hypovolemia, hypoxemia, metabolic disorders), with pathological changes in myocardium (injury, exhausting its energy resources). The cessation of blood circulation is indicated: the loss of consciousness, decreased blood pressure to zero, the disappearance of the pulsation of the sleepy arteries, the absence of heart tones, stopping the breath, the maximum expansion of pupils with the disappearance of their reaction to light, the range lexia, the appearance of heart muscle fibrillation or asistolia on the ECG forerunning stop Hearts can be a sharp change of pronounced tachycardia on bradycardia, as well as the strengthening of the pallor of the skin and mucous membranes ("Dead" pallor).

With anglative injury, the inspection starts from the area of \u200b\u200bdamage. Carefully free it from clothes and shoes; Deformation, hematoma, asymmetry of limbs, forced position, function disorders, pain areas, skin detachment, muscle break, tendons.

If the victim is asked to find out the mechanism and the injury force, the patient's position at the time of injury was whether the injury was direct or indirect. The identification of victims with a certain character and severity of injuries is of great practical importance. Automotive injury, catathamma, Barotraham has currently become synonymous with heavy multiple damage - polytrauma. At the same time, the death of victims is more often associated with asphyxia, acute blood loss, acute oppression of the functions of vital organs (brain, heart).

Sustal examination of victims are carried out in a certain order: head, neck, chest, belly, pelvis, spine, limbs. The main receptions of the survey are inspection, palpation, percussion, auscultation, determination of the amplitude of movements in the joints, review and local radiography. The main tools of the orthopedic traumatologist during examination of patients - a centimeter tape and a tilter. Comparative measurement of the length of limb (relative, absolute), axial lines, circles, amplitudes of active and passive movements in the joints must be made in all patients.

Unlike damage, orthopedic diseases do not have a clear boundary of pathological changes. Pain syndrome, forcing the patient to contact the doctor, is usually late manifestation of the pathological condition. When collecting anamnesis, it is necessary to clarify the hereditary factors, possible generic injuries, transferred infectious diseases obtained in childhood, but forgotten injuries.

The survey scheme also includes the definition of morphofunctional changes in dosage loads, analysis of the results of laboratory studies, surgical interventions (puncture, biopsy).

When studying complaints, the timing and nature of the start of the disease, provoking factors, features of pain, to pay attention to the position of the patient when walking, sitting, lying, on his psyche and behavior. When collecting anamnesis, it is important to find out the suffering diseases, injuries, allergic reactions, living conditions and work. Skillfully assembled history correctly focuses the doctor in addressing the issues of diagnosis, therapeutic tactics, the volume of interventions.

A thorough examination helps to avoid many diagnostic errors. According to the general type and position of the patient, the expression of his face, the skin color can be assessed by the severity of the general condition and the predominant localization of the pathological focus. According to a typical position, the characteristic position of the limb, an experienced doctor may diagnose "at first sight". But this does not exclude the need for a full-fledged survey. The passive position of the limb may be a consequence of the bruise, fracture, the car, paralysis. The forced position is observed with a pronounced pain syndrome (gentle installation) in the spine or limb area, with violations of mobility in the joints (dislocation, contracture), as a result of compensation for the shortening of the limb (skew pelvis, scoliosis).

In case of inspection, impaired forms and outlines of limbs and body parts. Violation of the axis of the limb segment, the angular and rotational deformation indicate a fracture, the disturbance of the axis of the entire limb is more often associated with orthopedic diseases. Many orthopedic diseases received the names of typical deformations of the skeleton - closure, spruce, krivoshima, flatfoot, scoliosis, kyphosis, etc.

Comparative measurements use bone protrusions on the limbs and torso.

An acromion, ulnar process, cylinding processes of the elbow and radiation bones are served on the hand by identifying points. On the lower limb - the upper front iliac reside, a large thigh spit, distal ends of the thighs, the head of the small bone, the lateral and medial ankle (Fig. 31). On the torso - a mild process, the corners of the blades, the awesome processes of the vertebrae.

The axis of the lower limb is the straight line connecting the upper front iliac auxer and the first foot of the foot. Normally, the lateral edge of the patella is located on this axis, with the Valgus curvature, the patella is shifted to the medial from the axis of the side, during the varetle - in lateral (Fig. 32).

The axis of the upper limb is the straight line, connecting the head of the shoulder bone, the head of the math of the shoulder bone, the head radius and the head of the elbow bone. With the Valgus deformation, the head of the elbow bone is located laterally axis, with a varetle - medial (Fig. 33).

The length of the lower limb is measured by the distance from the upper front ileal oce to the medial ankle. The thigh length is determined from the top of the large spit to the articular slot of the knee joint, the length of the leg - from the articular slot to the lateral ankle.

Fig. 31. Scheme of comparative measurements for bone protrusions

The length of the upper limb is measured from the acromion to the cylinder radial bone or end of the III of the finger, the length of the shoulder is from the acromion to the elbow process, the length of the forearm is from the elbow process to the cylinder elbow bone transformation (Fig. 34).

The shortening of the limb can be true (anatomical - in shortening the bones of one of the segments), relative (when dislocated), projection (under bending contractures, ankylose), total (functional - when walking, standing, when all available views are folded).

Measuring the circumference of the segments of the limbs and joints is strictly on symmetric areas. Repeated measurements are performed at the same level, the references are bone protrusions. The amplitude of the movements in the joints is determined by a tilter. For the starting position, the vertical position of the body and limbs take. The branches of the sensor are installed along the axis of the articular segments, and the axis is combined with the joint axis (Fig. 35). Flexing and extension are carried out in the sagittal plane, the lead and bringing - in frontal, rotary movements - around the longitudinal axis.

Fig. 32. The axis of the lower limb: a - norm; B, B - Vius and Valgus County

Fig. 33. The axis of the upper limb: a - norm; B, B - Vius and Valgus County

Depending on the nature of the violation of mobility in the joint distinguishes:

1) Ankylosis (complete immobility);

2) rigidity (swinging movements);

3) Contracture - restriction of mobility during bending (extension-based contracture), in extension (flexing contracture), when administered (leading contractures).

Fig. 34. Measurement of the length of the limbs: A - the relative length of the lower limb; b - the length of the hip; in - lower leg length; r - relative length of the upper limb; d - length of the shoulder; E - forearm length

Fig. 35. Measurement of the amplitude of movements in the joints: A - shoulder dilution; b - flexion in the shoulder joint; B - flexion in the elbow joint; g - flexion-extension in the ray-exclusive joint; d - bringing a brush assignment; e - the harness of the hip; Well - flexion in hip and knee joints; W - flexion-extension in the ankle joint

Ankyloses are true (bone) and false (fibrous), which is specified by the radiograph. Ethiology also allocate different kinds Contractures: Dermatogenic, Desmogenic, Tendogenic, Moiogenic, Ar-Trogenic, Neurogenic, Psychogenic, Mixed.

During the examination of the orthopedic patient, important information is obtained using the methods of outcading contours, prints, plaster blinds, photoregation, optical topography (Fig. 36).

Fig. 36. Blank with optical topography results

Determination of excess mobility, unusual ("pathological") mobility in the joints, throughout the bone segment of the limb may be crucial for diagnosis.

Radiation research methods

Radiological studies are the main method of diagnosis and control in the treatment of orthopedic and traumatological patients. In the direction of x-ray examination, the doctor should indicate the exact localization of the pathological focus, standard and additional projections, functional loads and positions, additional conditions (targeted radiography, radiography with primary increase in the image, etc.).

On the radiograph of the bones of the limbs, one of the adjacent joints should be visible, and with pathological foci at different levels - both adjacent joints. The spine, the pelvis, the chest must be investigated at the beginning on sightsets, then on target.

Typical changes in bones and joints are:

1) Aplasia (congenital absence of bone);

2) hypoplasia (bone underdevelopment), hyperplasia (increasing bone tissue, acceleration of development);

3) atrophy (reduction of mass and volume of bone tissue);

4) osteoporosis (reducing the bone density due to thinning and reducing the number of bone beams);

5) osteosclerosis (enhancing the bone density due to the thickening of bone crossbar);

6) periostost (layering of bone tissue on the bone surface);

7) hyperostosis (excessive breaking of the bone in width);

8) hypioshosis (thinning of the cortical bone layer);

9) osteopetrosis (thickening of a compact substance);

10) osteomalacia (decalcination and softening of bones with the development of deformations);

11) Osteopoykilia (spottedness of epiphysis due to the formation of compact bone processes);

12) Osteodysplasia (abnormalities of bone development);

13) osteodistrophy (restructuring of the bone structure with fibrous bone substitution);

14) osteonecrosis (samples of the bone tissue, the formation of sequesters);

15) osteophytes (small periostal bone growths);

16) exostosis (large periosk bone growths);

17) osteoarthropathy (damage to the articular ends of bones);

18) arthrosis (hyperostosis and deformation of the articular ends of bones with a violation of the congruence of the joint surfaces, the narrowing of the articular slit);

19) arthrosclerosis (sclerosis of the articular capsule);

20) osteochondrosis (dystrophy of bone and cartilage tissue);

21) osteochondrolysis (resorption of the epiphyse area with articular cartilage).

X-ray picture of fractures.The main feature: a linear or curly break of the bone structure and contour of the bone.

Localization: a diaphyseal (proximal, medium, distal third), metaphyseal (otolossert), epiphyseal (intra-articular) epiphysis-oliz (fracture along the line of the sprout zone with an offset of epiphyse).

Character: transverse, longitudinal, oblique, screw-shaped, consolidated, multiple, compression, framed, edge, tearing.

The displacement of fragments: in length (with the ending, discrepancy), in width, at an angle, by periphery (rotational).

X-ray pattern dislocation.The main feature: the complete separation of the articular ends of the bones, with a sublifting - partial contact of the joint surfaces, but with deformation of the contours of the articular slit (excess expansion, uneven narrowing, etc.). It should be distinguished

Fig. 37. Speakers of the joints: a - shoulder; b - elbow; in - ray-exclusive; g - hip; d - knee; E - anklestopny

Fig. 38. Magnetic resonance (A, B) and computer (b) tomograms of the knee joint: a - fracture of the outer facet of the patella; b - a creeping perestroika of the outdoor math of femur; B - Damage to the anterior cruciform ligament

the bone fracture with the dislocation of the intact articular end of it and the fracture is the fracture of the dislocated articular end of the bone.

Displacement: front, rear, proximal, distal, lateral, medial, central.

With the help of arthroprographic to the body cavity, by puncture (Fig. 37), oxygen (sterile air), contrasting liquids, or simultaneous administration of gas and liquid (double contrast) - specify the nature of the pathological condition of the joint, detect free bodies in its cavity.

To identify some types of pathological conditions during radiography, special stacking is used: the position of Launcen is necessarily used to clarify changes in the head of the femur

perthes diseases, epiphisheolysis, functional pictures - with osteochondrosis, spondylolysis, spondyloliste, pictures of 3/4 - with spine damage, pelvis, brushes, feet.

Computed tomography (CT) and magnetic resonance imaging (MRI) significantly expand diagnostic capabilities during injuries (spinal fractures, pelvic bones, heating bones, damage to tendons, ligaments, meniscoves) and orthopedic diseases (tumors, aseptic necrosis, degenerative dystrophic diseases Spine and joints, osteomyelitis, honcopathy).

Examples of computer and magnetic resonance tomograms with some pathological conditions are shown in Fig. 38.

In the study of the patient, they usually resort to measurements of the length of the limb and its circle. Measurements produce both damaged and healthy limbs. The results obtained are compared, which gives an idea of \u200b\u200bthe degree of anatomical and functional disorders. The length and circumference of the limbs are measured by a conventional centimeter tape. Sample points with a comparative measurement of the length of the limb are bone protrusions. The patient with measurements should be properly laid: draw attention to the fact that the patient's pelvis is not cleared, and the line connecting both the front-upper astest was perpendicular to the middle line of the body. When determining the length of the lower limb is measured, the distance from the front of the upper ointle of the ileal bone to the lower edge of the inner ankle, when measuring the thigh length, determine the distance between the large spit and the articular slit of the knee joint.

The length of the lower leg is determined by measuring the distance from the articular slot of the knee to the lower edge of the outer ankle.

The length of the upper limb is measured by the distance from the acromic process of the blade to the cylinder radial bone process or to the end of the III of the finger, the length of the shoulder is from the edge of the acromial process to the elbow process or the outer blasting overhead, the length of the forearm is the length of the forearm - from the elbow process to the breadth of the elbow bone.

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

Types of shortening or lengthening limbs

Distinguish the following types of shortening or lengthening limbs.

1. True (shortening or elongation) is due to anatomical change in the limb and is determined by comparing the total data for measuring the length of the thigh and the legs (shoulder and forearm) on the damaged and healthy limb. True shortening is observed when the bone growth is delayed, displacing fragments, etc.
2. Apparent, or projection, shortening or elongation is due to the vicious installation of the limb due to contracture or ankylosis in the joint.

IN. Marx proposes to determine the projection shortening as follows: giving the patient the correct position in relation to the pelvis and the healthy limb, measure the length of the healthy limb, with the help of the same projection measure the length of the sick leg located in the maximum extension position (how much the contractures are in the joints allow). The difference in the layout of the identification points of a healthy and sore limb gives the magnitude of the apparent shortening.

The circumference of the limbs (patient and healthy) is measured in symmetrical places at a certain distance from bone identification points: for the leg - from the front of the upper axis of the ileal bone, the large skeleton of the hip, the articular slot of the knee joint, the head of the small berth bone; For hand - from acromic process, internal shoulder brave. For example, the measurement entry should be like this: The circle of a healthy thigh by 12 cm is proximal than the articular slot of the knee joint is equal to 56 cm. The circumference of the sore thigh at the same level is 52 cm. Reducing the circumference of the sick thigh -4 cm

Stop measurements are produced both with a load and without load.

The deformation of the foot as a result of static failure consists of:

• pronation of the back of the foot and compensatory relative supination of its front department;
• bending to the rear of the front stage of the foot in relation to the rear department installed in the position of the plantar flexion (the compassion of the foot);
• the leads to the front of the back of the foot Abduccia) in relation to its rear.

By M.O. Friedland Stop is installed before measuring on a blank sheet of paper. Foot contours are delineated by a pencil, which is kept vertically. According to the circuit, the circuit is measured:

• the length of the foot from the top of the fingers to the end of the heel;
• width of the foot i-V level Plus-phalange articulation ("big" width);
• the width of the foot at the level of the rear edge of the ankle ("small" width).

Fit size definitions

The height of the foot is determined by the measurement of the vertical, rising from the floor to the highest point of the foot (area of \u200b\u200bthe lands), which is located at a distance of 1.5-2 cm from the front surface of the lower leg. For these measurements, they use a circulation, ruler or stopmers.

The change in the longitudinal arch can be judged by the magnitude of the submometric index of Friedland, which is calculated. The index from 31 to 29 has a normal foot, from 29 to 25 - a decrease in the arch, a flat stop less than 25 is a sharply pronounced longitudinal flatfoot.

F.R. Bogdanov recommends measuring the longitudinal arch of the foot by building a triangle, the identification points of which are easily accessible to feeling. These points are: head I hanging bone, heel borgon and the peak of the inner ankle. By connecting these three points, the triangle is obtained, the base of which is the distance from the head of the first tie bone to the heel bent. The calculation leads to the height of the arch and the size of the angles in the inner ankle and in the heel bone. Normally, the height of the arch is 55-60 mm, the angle at an ankle is 95 °, the angle of the heel bone is 60 °. With a flat foot: The height of the arch is less than 55 mm, an angle at an ankle 105-120 °, an angle in the heel bone of 55-50 °.

Degree definitions of flatopy

To determine the degree of flatopyopy, the X-ray method of the study is used. The calculation is based on the construction of a triangle, the vertices of which are the head of the tie bone, the latal bone and the fifth of the heel bone, and measuring the height of the arch and the magnitude of the corner from the lands.

• When flatfooting I degree: the height of the arch is less than 35 mm, the angle of the latal bone is up to 140 °.
• When flatfooting II degrees: the height of the arch of 25 mm, the angle of the lands to 155 °.
• When flatfooting III degrees: the arch is absent, the corner of the lands to 170-175 °.

Determination of the rear stop of the foot

Determination of the premonition of the rear feet of the foot (the heel) is performed during the axial load (the patient is on the stacked stop). On the rear surface of the head of the middle line, the Achille tendons are carried out by an axis, which goes to the middle of the heel beam. Normally, the axis of Achilles tendons and heels merges with the line of the plumb. The deviation of this axis of the dust from the vertical obtained using a plumb, gives the corner of the rear section of the deformed foot.

Determination of the leading of the front stop

The leading of the front stop (abduccia) is determined by the outline of the external circuits of the studied foot. Obligating the outlines of the ankles. After that, connect the most protruding parts of the ankle contours. The axis of the normal foot passes through two points: through the middle of the tip II of the finger and the middle of the bimalolar line. If you continue the axis of the foot towards the heel, then with the normal structure of the foot, most of the outlined heel is located Knutrice from the foot axis. The foot axis forms an angle less than direct angle with bimelolar line. With a flat (envelope) foot, this angle is more direct, which shows the presence of the leading stop of the foot; The magnitude of the deviation angle gives an idea of \u200b\u200bthe degree of severity of the abduction. By the location of the axis on the outlined heel contour, it is possible to determine the degree of pronation of the rear feet. All measurements of the foot need to be produced symmetrically on both legs.

Determination of spinal curvatures

The curvature of the spine may occur in three planes:

• frontal (lateral curvature-scoliosis);
• sagittal (round spin, hump - kyphosis);
• horizontal (rotation of the vertebrae - torsion).

Measuring the side curvature of the spine is carried out in the position of the patient standing.

On the body, they mark the line of spiny processes from the upper cervical to the lower edge of the sacrum. From the rear edge of a large occurring hole, the skull is lowered a plumbing thread. In the absence of lateral curvature of the line of the plumb and the oscent processes coincide. In the lateral curvature of the spine, the line of spisy processes forms arcuate deviations from the vertical.

The magnitude of the lateral deviations of the line of spiny processes from the vertical straight line is measured in centimeters at the level of maximum curvature. Determine the intersection points of vertical and arcuate lines. These measurements are transferred to a sheet of paper, on the same image, lines are applied connecting the acromial processes of the blades and ridges of the iliac bones. Normally, these lines are parallel between themselves and perpendicular to the plumb. Spit standing pelvis and adequate breaks this ratio.

Measurement of the head-rear curvature of the spine with a sharply pronounced deformation (pointed hump) is made using a tilter. When round humps and arcuate kifoses make out an outline with a pencil on paper or fixed with wire or plaster cast.

A.P. Skoblin, Yu.S. Villa, A.N. Jeresel

"Methods for measuring sizes and shape of the limbs during examination" - section

Changing the length of the limb (more often towards shortening) - a frequent and important sign of the pathology of the musculoskeletal system. The shortening of the limb occurs as a result of a dislocation or fracture, as a result of the displacement of fragments, as a result of the consequences of injury, for example, incorrectly hitting the fracture, joint contractures, with many diseases of the musculoskeletal system associated with the trophic violation or formation of the bone tissue.

The general rule of measurement is the comparison of symmetric areas using symmetric bone protrusions with the same position of the limbs or the neutral position of the body.

The qualitative definition of changes in length is carried out by comparing the level of bone protrusions (Fig. 11-11-11-14). It must be remembered that sometimes deformation of the pelvis, the spine, the adapter can level the difference in the length of the limbs. The elimination of deformation gives an idea of \u200b\u200bthe presence of shortening.

Fig. 11-11.Shoulder shortening determined by comparison

Fig. 11-12.Shortening of the forearm determined by comparison

Fig. 11-13.Shooting shores determined by comparison

Fig. 11-14.Shortening of the left leg, determined by comparison

The exact quantitative measurement is carried out using a measuring tape or special lines. To clarify the localization of pathology, the total dimension of the entire limb and the measurement of its segments is carried out.

The length of the hand, as a rule, is measured from the acromic proof of the blade to the end of the III of the finger of the brush (Fig. 11-15). The bone benchmarks for measuring the shoulder are the acromic process of the blade and the elbow process, for the forearm - the elbow process and the cylinder outer bone outflow (Fig. 11-16, 11-17).

Fig. 11-15.Hand length measurement total

Fig. 11-16.

Fig. 11-17.Hand length measurement in segments

Fig. 11-18.Leg length measurement total

The total length of the legs is measured from the front of the upper axis of the ileal bone to the tops of the inner or outer ankle (Fig. 11-18). To measure the hips, the distance from the top of the large spit to the articular slot of the knee joint is determined (Fig. 11-19), for measuring the shin - the distance from the knee gap to the outer ankle.

The length of the adapter is determined by the distance from the sternum end of the clavicle to the acryal reproduction of the blade (Fig. 11-20).

Fig. 11-19.Measuring foot length in segments

Fig. 11-20.Determination of the length of the adapter

When measuring the total length of the limb, the true (absolute or anatomical), relative and apparent (projection) change in length (Fig. 11-21) differ. Most often we are talking about shortening. The true shortening of the limb is the change in the total length due to the shortening of the segment. Such shortening occurs during fractures, incorrect bones, with violations of the bone growth, etc. The relative change in length occurs when one segment is displaced relative to the other, with a constant length of the limb itself, for example, when dislocated. Apparent, or projection, shortening is shortening the projection of the limb to a straight plane with its unchanged length during segmental dimension. This type of shortening is more common in the contractures of the joints.

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Along with the meaning of diagnosed changes, we also take into account practical and methodological aspects, since not all methods are equally effective and "economical".

For example, the needlerapy or local anesthesia of the pearly peppercourts is much more economical than the massage of the periosteum, but when it comes to the point of attachment of the muscles, we, if possible, give preference to the postisometric relaxation, because it is painless and in most cases patients can perform it independently.

The advantage of manipulations consists in their effectiveness and speed of use.

Having big choice Adequate techniques, we often make a decision when exactly recognize individual changes. In such cases, we put the "working diagnosis", which means our difficulty in clarifying precisely those changes that represent the most important link in the pathological chain.

We re-clarify whether the methods of skin irritation were not applied without a proper estimate of the patient's survey data, without information about the hyperalgesia zone or muscle relaxation, if you do not find muscle tension, if at least one manipulation was carried out without blocking.

Naturally a big time loss when appointing medical gymnastics without preliminary identification of impaired muscle coordination. The correct pathogenetic diagnosis can only be delivered in cases where individual tracks of pathogenesis are identified and their meaning is analyzed.

Only at the same time, after subsequent treatment, we can expect certain results. Thus, it is necessary, as in a neurological study, systematically move from the periphery to the center, and then begin treatment according to the data obtained.

However, it happens that the results do not meet our expectations. The reason for this may be damage, which causes increased nociceptive irritation and distorts the clinical picture, which the patient does not suspect.

It seems to us expedient to stop at such a concept as a crunch in the joint, in most cases accompanying successful manipulation. It is known that this phenomenon can be in healthy joints of the limbs and spine, having no meaning (for example, a crunch while stretching the fingers on hand), and on the contrary, we know from our patients that pain often arise from them after a sinister cod in Sustaines in the field of a sacrum or a lower back, and we understand that this phenomenon should be regarded as an anamnestic sign.

When manipulating treatment, a successful receipt is accompanied by a crunch in the joint, but experience shows that in most cases this crunch indicates the success of manipulation, and it is in these cases a typical reflex phenomenon (muscle hypotension, a feeling of heat, etc.) occurs. Even simple manual traction is particularly effective if the crunch in the joint appears.

With long-term observation, it is possible to distinguish an ordinary crunch on a rumor, which can be caused in any joint, from that characteristic click, which occurs when the blocked joint is released. Terrier believes that the usual crunch in the joint in the spine can not be repeated after a short period of time.

In the treatment of blocked joint, it happens that the first cautious manipulation does not give effect, causing only a normal crunch in it, however, when re-manipulation, a repeated characteristic click occurs. This difference in acoustic phenomenon indicates a significant difference between the usual crunch in the joint and the blocking process.

The common between them is that the structure that generates this acoustic phenomenon is likely to have a joint itself. When we later consider the essence of the blocking of the joint, this conclusion will play a role.

However, it is not worth it and overestimate the meaning of this phenomenon: if, when manipulating reception, he talks about achieved successWhen mobilization in most cases, blocking is removed without this phenomenon. We can further enter this problem - only discussing the reversible blocking of the joints.

Ways to diagnose the value of the functional difference between the length of the lower extremities (FRC)

The definition of the value of the FRC is a rather complicated task. Currently, a large number of ways and devices are known to determine this value, but each of them has significant methodical and constructive disadvantages that do not allow sufficient accuracy to determine the value of the FRDNA, and sometimes lead to false diagnosis.

Conditionally all known methods for determining the magnitude of the functional difference of the length of the lower extremities can be divided into three groups:

1. Visual inspection and palpation;
2. Radiological measurement techniques;
3. Anthropometry.

Visual inspection and palpation

According to literary data, the most common way of visual and palpator diagnostics, the presence of a functional difference between the lower limbs is to determine the levels of laying both half the pelvis. In a patient who is in a vertical position, the doctor locks the most high Points On the ridges of the iliac bones or their rear tops and visually compares their levels. J. G. Travell and D. G. Simons believe that for the inspection of the patient should be to the doctor's doctor (legs together, the knees are straightened).

The difference in the length of the legs is determined by palpation of the ridges of the iliac bones or their rear upper arms. The patient should examine the spine for scoliosis in the breast and lumbar departments, the presence of an inclination of the axis of the shoulder belt, as well as the position of the blades, which is determined by the palpation of the levels of the standing of their lower corners.

For approximate correction of a short leg, the authors offer to put a pack of paper or a small magazine under it, while the patient should not have any inconvenience. For one to two minutes, the conversation is supported with patients and customize it to relax and distributed body weight on both legs.

When the short foot muscle approaches, compensated by the difference in the length of the legs, are released from this function and relax. This makes it possible to more accurately compensate the difference in the length of the legs, additionally lifting a short leg until the sorry, while the pelvis and shoulders are aligned horizontally and, most importantly, the spine is not aligned.

For confidence in the accuracy of the correction, a short leg raise another 1-2 mm, and if the correction was really accurate, then the pelvis, and sometimes the shoulder belt, as a result of the excessive lifting of the legs bends in the opposite direction.

The method described above the measurement of the FRDNA value using a pack of paper or a magazine can hardly be perceived seriously from the point of view of the accuracy of the data obtained.

According to V. J. Sicuranza and co-authors, with visual inspection it is necessary to pay attention to the following symptoms. The hand on the side of the short leg is deflected from the torso to the side, while the other hand is pressed against it. On the side of the long feet of the waist and protrusion of the hips is more pronounced.

On the side of the short leg, the buttock is omitted. On side from the side opposite to the convexity of the arc lumbar Department Spine, is significantly more skin folds. The authors also note that in some cases, it is carried out to determine the presence of FRDNA, a palpator comparison of the height of large skewers of femur bones is carried out.

The original way to determine the presence of a functional difference between the length of the lower extremities suggested R. Maigne. The patient is asked to shake forward - back first, and then another foot. At the same time, the short leg swings freely with a minor change in body position, whereas for swing a long leg a patient is forced to shift half the pelvis on this side up so that the feet do not hurt the floor.

In cases where Visual and palpator data for the presence of FRDNA diffuse, especially when scoliosis remains after leveling levels hip joints, It is necessary to look for a possible sacrum position overcast, i.e. twisted pelvis.

Summing up the above, it should be noted that the visual inspection and palpation is only with a greater or lesser degree of probability allow the doctor to suspect the presence of FRC patient. A significant disadvantage of the methods described is the impossibility of accurately determining the value of the functional difference of the length of the lower extremities.

The presence of FRC, as is known, leads to the asymmetry of the distribution of static and dynamic loads for each of the lower extremities. On foot having a large functional length, there is a big load.

Methods of computer communications of vertebrate motor segments

The CT-study of PDS in order to diagnose degenerative-dystrophic pathology requires a higher resolution technique than in the study of other organs. In particular, the size of PIXEL should be at least 1 mm. Cutting thickness 4-5 mm is usually sufficient for adequate visualization of the disk substance, bone structures, a fool bag and its contents. Thin thin sections of 1.5-2 mm are used to clarify small parts.

The position of the patient during the study - lying on his back with bent in hip and knee joints, which is achieved by smoothing the physiological lumbar lordosis.

The study begins with the work of a review shot - a side tomogram. Most authors recommend the method of inclination of Gentry (scanning device), respectively, the plane of the PDS studied. Setting the levels of cuts and angle of inclination of Gentry is made by side tomogram.

For visualization of the spinal roaster, on all its intraspel, it is necessary that the sections are performed on the level of the alignment vertebrae to the level of the underlying vertebra. If you need to get a reformed image, in this regard, only one PDS will be included in the reformation.

THEM. Danilov, V.N. Naboychenko