Measurement of the anatomical length of the upper limb. Methods for measuring the length of the limbs and the range of motion in the joints. Technique of computed tomographic study of vertebral motor segments

Measuring the length and circumference of the limbs.

The length of the limbs is measured by two methods that complement each other: the comparison method (using symmetrical bone protrusions) and using measuring instruments. The length of the upper limb is measured from the apex of the acromion to the styloid process of the radius or to the end of the third finger; shoulder length - from the edge of the acromion to the olecranon or to the lateral epicondyle of the humerus; the length of the forearm - from the olecranon to the styloid process of the ulna.

The length of the lower limb is determined by measuring the distance from the superior anterior iliac spine to the medial malleolus (Fig. 4); the length of the thigh - from the greater trochanter of the femur to the joint space of the knee joint, the length of the lower leg - from the joint space of the knee joint to the edge of the lateral ankle.

For fractures of the pelvic ring with an offset, it is necessary to find out if there is a shortening of the limb. To do this, measure the distance from the xiphoid process to the upper anterior iliac spines.

There are the following types of limb shortening or lengthening:

1. Anatomical, or true, shortening - is observed with delayed growth of the limb, damage to the epiphysial cartilage, displacement of fragments; measured by the bony prominences of the long bones.
2. Apparent, or projection, shortening is caused by a faulty limb installation 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 a healthy one, although there is no anatomical shortening of the bone).
3. Relative shortening - occurs with changes in the location of the articulating segments (dislocations) and is measured, for example, on the lower limb from the upper anterior iliac spine to the medial ankle in comparison with a healthy leg, installed, if possible, in the same position with the patient. It is necessary that the pelvis is in the correct position and both upper anterior iliac spines are in line.
4. Functional shortening - is determined when the patient is upright. To do this, under the shortened leg, boards with a height of 1 - 1.5 cm are substituted until both upper anterior iliac spines of the pelvis are at the same level. The existing compensatory curvature of the spinal column usually disappears, the patient stands confidently on his feet. The height of the planks placed indicates the degree of functional shortening.

The circumference of the limbs is measured in symmetrical places at certain distances from the bone identification points. With subsequent measurements of the circumference of the injured limb, an increase in edema, hematoma, an increase in effusion in the joint, and muscle atrophy are observed.

Correct and fast diagnosis is the key to successful treatment. An approximate diagnosis is determined by the information that eyewitnesses report at the scene when they call an ambulance. The basis for such a diagnosis is the circumstances of the injury, the general condition of the victim and obvious injuries that can be established by a non-specialist. More accurate information is reported by traffic police officers, police, medical workers. The preliminary diagnosis (prehospital) is established by the doctor of the ambulance team and the traumatologist of the polyclinic or trauma center. Central to this diagnosis is the identification of life-threatening injuries or injuries that can lead to fatal complications. Purposeful

A careful search for such injuries is an important diagnostic principle in acute trauma.

The quality of the preliminary diagnosis depends on the experience and knowledge of the traumatologist. The accuracy of the preliminary diagnosis, in turn, determines the tactics, focus and amount of care at the prehospital stage.

Definitive diagnosis of superficial trauma, simple fracture (ankle, forearm, hand, foot), dislocation installed, as a rule, in a trauma center during the initial treatment using standard radiography.

For definitive diagnosis of complex trauma(fractures of the bones of the leg, hip, shoulder, pelvis, spine, TBI, polytrauma), several specialists are required to participate in the examination of the victim: an orthopedic traumatologist, neuropathologist, neurosurgeon, ophthalmologist, radiologist, etc.

Clarify the nature of the damage using modern methods radiation diagnostics - radiography, computed tomography (CT), magnetic resonance imaging (MRI), angiography, radionuclide diagnostics; biomechanical, electrophysiological, biochemical, immunological diagnostic methods. Auxiliary diagnostic tools are ultrasonography, Doppler ultrasonography, thermography, rheovasography, polarography and other research methods.

The general view of the patient, his physical activity, mental state immediately orient the doctor in relation to the severity of the injury. Elucidation of the mechanism of injury and the duration of the post-traumatic period determines the tactics of examining the victim. With an isolated minor injury, the doctor has the opportunity to familiarize himself with the history in detail: how he fell, how he lay, what he felt, were able to stand up on his own, etc. Good contact with the victim, who clearly expresses his complaints, greatly facilitates the diagnosis.

In severe polytrauma, accompanied by impaired consciousness in the victim, the diagnostic examination is carried out simultaneously with the provision of staged assistance, resuscitation and treatment. Despite the variety of combinations of various lesions, in the clinical picture of severe polytrauma, several main traumatic foci can be identified that directly threaten the victim's life.

In multiple injuries, one of the main causes of traumatic shock is blood loss. If the victim is unable to quickly establish the cause of the low blood pressure, one should, first of all, think about latent bleeding, the source of which is most often damage to the spleen and liver (intra-abdominal bleeding), fractures of the pelvic bones (retroperitoneal bleeding), damage to the intercostal arteries with fractured ribs (intrapleural bleeding), fractures of the thigh and lower leg (interstitial bleeding). In patients with extensive muscle crushing, with an acutely developing infection (gas gangrene, peritonitis), life-threatening hypovolemia may result from accumulation of blood and loss of plasma in the area of ​​extensive inflammatory and toxic edema.

An aggravating factor in the development of severe shock and terminal conditions is acute respiratory failure(ONE). Severe disorders of gas exchange in the lungs occur with multiple fractures of the ribs (especially with the formation of a "costal valve"), bruises of the lungs, pneumo- and hemothorax.

At brain damage the clinical picture is characterized by long-term disturbances of consciousness, respiration, and blood circulation. General cerebral symptoms are manifested in the form of extreme deviations from the norm: tachycardia, bradycardia, arterial hyper or hypotension (due to concomitant blood loss). Respiratory disorders are characterized by a special diversity of clinical forms: from complete stop and gross rhythm disturbances to central hyper- and hypoventilation with a sharp increase or decrease in the respiratory rate (RR). Terminal disorders of ventilation of the lungs in severe cases are associated either with primary destruction of the brain stem, or with its secondary compression by hematoma or edema. With hyperventilation of central origin, hypoxia develops rapidly with its negative effect on hemodynamics and metabolic processes. With hypoventilation, dangerous cardiac disorders (up to asystole) occur due to hypercapnia and hypoxemia. Central breathing disorders, as a rule, are accompanied by peripheral, associated with impaired airway patency.

In 80% of cases of severe TBI, the immediate cause of death is asphyxia. The most severe disorders of the function of the external respiration apparatus develop when TBI is combined with multiple rib fractures.

Prolonged, more than a day, loss of consciousness, areflexia, lack of spontaneous breathing, paralytic dilated pupils, electrical "silence" of the brain usually indicate irreversible changes in the cells of the brain, about "brain death". The death of the brain can be caused by compression of it by a hematoma or edema. Signs of increasing intracranial pressure: progressive deterioration of the general condition of the victim, deepening of cerebral coma, respiratory and hemodynamic disorders, increased stiffness of the muscles of the neck and back, increased cerebrospinal fluid pressure. In alcoholic victims, signs of traumatic brain injury may not fit into the typical clinical picture. However, to explain the severity of the condition of patients with polytrauma by alcohol intoxication (poisoning) alone is a gross mistake.

Heart contusions most often occur in road traffic accidents (RTA) and falls from a height, usually combined with damage to the chest, pelvis, limbs, skull. Clinically, heart contusions are manifested in the form of a syndrome of cardiogenic hypocirculation: pain in the region of the heart, anxiety, fear, a feeling of suffocation, numbness of the fingers, weakness, confusion, an earthy gray with a bluish tinge skin color, skin moisture, cold sweat. Large veins are swollen, periodically pulsate, signs of pulmonary edema may appear. Pulse of weak filling, arritis

mia, severe tachycardia, low pulse pressure, low blood pressure, high CVP. Detailed information about the presence and nature of heart damage is provided by an ECG (signs characteristic of myocardial infarction).

In severely injured people with polytrauma, there is always a threat of sudden cardiac arrest. It can be associated with a reflex factor (for example, with vomiting, suction of mucus from the trachea), with a sharp deterioration in the conditions of cardiac activity (acute hypovolemia, hypoxemia, metabolic disorders), with pathological changes in the myocardium (contusion, depletion of its energy resources). Cessation of blood circulation is indicated by: loss of consciousness, decrease in blood pressure to zero, disappearance of pulsation of the carotid arteries, absence of heart sounds, cessation of breathing, maximum dilation of the pupils with the disappearance of their reaction to light, reflexia, the appearance of fibrillation of the heart muscle or asystole on the ECG Harbinger of stopping the heart can be a sharp change in pronounced tachycardia to bradycardia, as well as increased pallor of the skin and mucous membranes ("deathly" pallor).

In case of a minor injury, the examination begins with the area of ​​damage. Carefully release her from clothes and shoes; reveals deformities, hematomas, asymmetries of the extremities, forced position, dysfunctions, pain zones, skin detachment, rupture of muscles and tendons.

When questioning the victim, it is necessary to find out the mechanism and strength of the injury, the position of the patient at the time of the injury, whether the injury was direct or indirect. Identification of victims with a specific nature and severity of injuries is of great practical importance. Automobile injury, catatrauma, barotrauma have now become synonymous with severe multiple injuries - polytrauma. At the same time, the death of the victims is more often associated with asphyxia, acute blood loss, acute suppression of the functions of vital organs (brain, heart).

Systemic examination of the victims is carried out in a certain order: head, neck, chest, abdomen, pelvis, spine, limbs. The main methods of examination are examination, palpation, percussion, auscultation, determination of the range of motion in the joints, survey and local radiography. The main tools of an orthopedic traumatologist when examining patients are a measuring tape and a protractor. Comparative measurement of the length of the limb (relative, absolute), axial lines, circles, the amplitude of active and passive movements in the joints must be performed in all patients.

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

The examination scheme also includes the definition of morphological and functional changes during dosed loads, analysis of laboratory results, surgical interventions (puncture, biopsy).

When studying complaints, it is necessary to clarify the timing and nature of the onset of the disease, provoking factors, features of pain, pay attention to the position of the patient when walking, sitting, lying, on the state of his psyche and behavior. When taking anamnesis, it is important to find out the past illnesses, injuries, allergic reactions, living and working conditions. A skillfully collected anamnesis correctly guides the doctor in solving issues of diagnostics, treatment tactics, and the scope of interventions.

A thorough examination helps to avoid many diagnostic errors. By the general appearance and position of the patient, the expression of his face, the color of the skin, it is possible to assess the severity of the general condition and the predominant localization of the pathological focus. According to the typical posture, the characteristic position of the limb, an experienced physician can make a diagnosis "at a glance." But this does not exclude the need for a full examination. The passive position of the limb can be the result of injury, fracture, paresis, paralysis. Forced position is observed with severe pain syndrome (gentle setting) in the spine or limbs, with disorders of joint mobility (dislocation, contracture), as a result of compensation for limb shortening (pelvic tilt, scoliosis).

On examination, violations of the shapes and outlines of the limbs and body parts are revealed. Violation of the axis of the limb segment, angular and rotational deformity indicate a fracture, violation of the axis of the entire limb is more often associated with orthopedic diseases. Many orthopedic diseases were named after typical skeletal deformities - clubfoot, clubfoot, torticollis, flat feet, scoliosis, kyphosis, etc.

For comparative measurements, bony protrusions on the limbs and trunk are used.

On the hand, the acromion, the olecranon, the styloid processes of the ulna and radius serve as the identification points. On the lower limb - the upper anterior iliac spine, the greater trochanter of the thigh, the distal ends of the femoral condyles, the head of the fibula, the lateral and medial malleolus (Fig. 31). On the body - the xiphoid process, the angles of the shoulder blades, the spinous processes of the vertebrae.

The axis of the lower limb is considered to be a straight line connecting the upper anterior iliac spine and I toe. Normally, the lateral edge of the patella is located on this axis, with valgus curvature, the patella is displaced medially from the axis, and with varus, it is lateral (Fig. 32).

The axis of the upper limb is considered to be a straight line connecting the head of the humerus, the head of the condyle of the humerus, the head of the radius and the head of the ulna. With hallux valgus, the head of the ulna is located lateral to the axis, with varus deformity - medially (Fig. 33).

The length of the lower limb is measured by the distance from the upper anterior iliac spine to the medial ankle. The length of the thigh is determined from the apex of the greater trochanter to the joint space of the knee joint, the length of the lower leg — from the joint space to the lateral ankle.

Rice. 31. Scheme of comparative measurements on bone protrusions

The length of the upper limb is measured from the acromion to the styloid process of the radius or the end of the third finger, the length of the shoulder - from the acromion to the olecranon, the length of the forearm - from the olecranon to the styloid process of the ulna (Fig. 34).

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

The measurement of the circumference of the segments of the limbs and joints is carried out strictly on symmetrical areas. Repeated measurements are necessarily performed at the same level, the bony protrusions serve as landmarks. The range of motion in the joints is determined by a protractor. For the starting position, the vertical position of the body and limbs is taken. The goniometer branches are installed along the axis of the articulating segments, and the axis is aligned with the axis of the joint (Fig. 35). Flexion and extension are carried out in the sagittal plane, abduction and adduction - in the frontal, rotational movements - around the longitudinal axis.

Rice. 32. Axis of the lower limb: a - norm; b, c - varus and valgus curvature

Rice. 33. Axis of the upper limb: a - norm; b, c - varus and valgus curvature

Depending on the nature of the violation of mobility in the joint, there are:

1) ankylosis (complete immobility);

2) rigidity (swinging movements are possible);

3) contracture - limitation of mobility during flexion (extensor contracture), during extension (flexion contracture), during abduction (adduction contracture).

Rice. 34. Measurement of the length of the limbs: a - the relative length of the lower limb; b - thigh length; c - the length of the lower leg; d - the relative length of the upper limb; d - shoulder length; e - the length of the forearm

Rice. 35. Measurement of the range of motion in the joints: a - shoulder abduction; b - flexion in the shoulder joint; in - flexion in elbow joint; d - flexion-extension in the wrist joint; d - adduction-abduction of the hand; e - abduction of the thigh; g - flexion in the hip and knee joints; h - flexion-extension in the ankle joint

Ankylosis are true (bone) and false (fibrous), which is specified on the roentgenogram. By etiology, they also distinguish different kinds contractures: dermatogenic, desmogenic, tendogenous, myogenic, arthrogenic, neurogenic, psychogenic, mixed.

When examining an orthopedic patient, important information is obtained with the help of techniques for outlining contours, prints, plaster casts, photo registration, optical topography (Fig. 36).

Rice. 36. Form with the results of optical topography

Determination of excessive mobility, unusual ("pathological") mobility in the area of ​​the joints, along the bony segment of the limb can be of decisive importance for diagnosis.

RADIATION METHODS OF RESEARCH

X-ray examinations are the main diagnostic and control method in the treatment of orthopedic and trauma patients. In the direction for an X-ray examination, the doctor must indicate the exact localization of the pathological focus, standard and additional projections, functional loads and positions, additional conditions (sighting radiography, radiography with primary image magnification, etc.).

On the radiograph of the bones of the extremities, one of the adjacent joints should be visible, and in case of pathological foci at different levels, both adjacent joints. Spine, pelvis, chest it is necessary to investigate first on survey images, then on sighting images.

Typical changes in bones and joints are:

1) aplasia (congenital absence of bone);

2) hypoplasia (bone underdevelopment), hyperplasia (an increase in bone tissue, accelerated development);

3) atrophy (decrease in the mass and volume of bone tissue);

4) osteoporosis (a decrease in bone density due to thinning and a decrease in the number of bone trabeculae);

5) osteosclerosis (increased bone density due to thickening of the bone bars);

6) periostosis (layering of bone tissue on the surface of bones);

7) hyperostosis (excessive bone growth in width);

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

9) osteopetrosis (thickening of the compact substance);

10) osteomalacia (decalcification and softening of bones with the development of deformities);

11) osteopoikilia (spotting of the pineal glands due to the formation of processes of compact bone);

12) osteodysplasia (anomalies of bone development);

13) osteodystrophy (restructuring of the bone structure with the replacement of fibrous bone tissue);

14) osteonecrosis (necrosis of a site of bone tissue, formation of sequesters);

15) osteophytes (small periosteal bone growths);

16) exostoses (large periosteal bone growths);

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

18) arthrosis (hyperostosis and deformation of the articular ends of the bones with impaired congruence of the articular surfaces, narrowing of the joint space);

19) arthrosclerosis (joint capsule sclerosis);

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

21) osteochondrolysis (resorption of an area of ​​the pineal gland with articular cartilage).

X-ray picture of fractures. The main sign: a linear or figured break in the bone structure and bone contour.

Localization: diaphyseal (proximal, middle, distal third), metaphyseal (periarticular), epiphyseal (intraarticular) epiphysis -olysis (fracture along the line of the growth zone with displacement of the epiphysis).

Character: transverse, longitudinal, oblique, helical, comminuted, multiple, compression, driven, marginal, detachable.

Displacement of fragments: in length (with overlapping, divergence), in width, at an angle, along the periphery (rotational).

X-ray picture of dislocations. The main symptom: complete separation of the articular ends of the bones, with subluxation - partial contact of the articular surfaces, but with deformation of the contours of the joint space (excessive expansion, uneven narrowing, etc.). Distinguish

Rice. 37. Puncture of the joints: a - shoulder; b - ulnar; in - wrist; g - hip; d - knee; e - ankle

Rice. 38. Magnetic resonance (a, c) and computer (b) tomograms of the knee joint: a - fracture of the outer facet of the patella; b - racemose reconstruction of the outer condyle of the femur; c - damage to the anterior cruciate ligament

bone fracture with dislocation of its intact articular end and fracture-dislocation - fracture of the dislocated articular end of the bone.

Displacement: anterior, posterior, proximal, distal, lateral, medial, central.

With the help of arthrography - injection into the joint cavity, by puncture (Fig. 37), oxygen (sterile air), contrasting fluids or the simultaneous introduction of gas and liquid (double contrasting) - the nature of the pathological condition of the joint is clarified, free bodies are identified in its cavity.

To identify some types of pathological conditions in X-ray, special packing is used: the Lauenstein position is necessarily used to clarify changes in the femoral head when

Perthes disease, epiphysiolysis, functional pictures - for osteochondrosis, spondylolysis, spondylolisthesis, pictures in 3/4 - with lesions of the spine, pelvis, hand, foot.

Computed tomography (CT) and magnetic resonance imaging (MRI) significantly expand the diagnostic capabilities of injuries (fractures of the spine, pelvic bones, calcaneus, damage to tendons, ligaments, menisci) and orthopedic diseases (tumors, aseptic bone necrosis, degenerative-dystrophic diseases spine and joints, osteomyelitis, chondropathy).

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

When examining a patient, they usually resort to measuring the length of the limb and its circumference. Measurements are made for both damaged and healthy limbs. The results obtained are compared, which gives an idea of ​​the degree of anatomical and functional disorders. The length and circumference of the limb is measured with a conventional measuring tape. Bony protrusions are the identification points in the comparative measurement of the length of the limb. When measuring, the patient must be correctly laid: pay attention to the fact that the patient's pelvis is not skewed, and the line connecting both anterior-upper spines is perpendicular to the midline of the body. When determining the length of the lower limb, the distance from the anterior superior iliac spine to the lower edge of the inner ankle is measured; when measuring the length of the thigh, the distance between the greater trochanter and the articular space of the knee joint is determined.

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

The length of the upper limb is measured by the distance from the acromial process of the scapula to the styloid process of the radial bone or to the end of the third finger, the length of the shoulder is from the edge of the acromial process to the olecranon or the outer epicondyle of the humerus, the length of the forearm is from the bone of the ulnar process to the styloid process.

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

Types of limb shortening or lengthening

There are the following types of limb shortening or lengthening.

1. True (shortening or lengthening) is due to an anatomical change in the limb and is determined by comparing the total measurement data of the length of the thigh and lower leg (shoulder and forearm) on the injured and healthy limb. True shortening is observed with a delay in bone growth, displacement of fragments, etc.
2. Apparent, or projection, shortening or lengthening is due to the faulty positioning of the limb due to contracture or ankylosis in the joint.

IN. Marx proposes to define the projection shortening as follows: after giving the patient the correct position in relation to the pelvis and the healthy limb, measure the length of the healthy limb, using the same projection, measure the length of the diseased leg, which is in the position of maximum extension (as far as contractures in the joints allow). The difference in the level of the location of the identification points of the healthy and diseased limbs gives the magnitude of the apparent shortening.

The circumference of the limbs (sick and healthy) is measured in symmetrical places at a certain distance from the bone identification points: for the leg - from the anterior superior iliac spine, the greater trochanter of the thigh, the joint space of the knee joint, the head of the fibula; for the hand - from the acromial process, the inner epicondyle of the shoulder. For example, the measurement record should be as follows: the circumference of the healthy thigh 12 cm proximal to the articular space of the knee joint is 56 cm.The circumference of the diseased thigh at the same level is 52 cm. The decrease in the circumference of the diseased thigh is -4 cm.

The feet are measured both with and without load.

Deformity of the foot due to static failure consists of:

• pronation of the hindfoot and compensatory relative supination of its forefoot;
• bending towards the rear of the forefoot in relation to the hindfoot, which is established in the position of plantar flexion (flattening of the foot);
• abduction of the forefoot abduction) in relation to its posterior part.

According to M.O. Place the Friedland foot on a blank sheet of paper before measuring. The contours of the foot are outlined with a pencil, which is held vertically. Measured along the outlined contour:

• the length of the foot from the top of the toes to the end of the heel;
• foot width by level I-V metatarsophalangeal articulation ("large" width);
• the width of the foot at the level of the posterior edge of the ankles ("small" width).

Determining the size of the foot

The height of the foot is determined by measuring the vertical that rises from the floor to the highest point of the foot (the scaphoid region), located at a distance of 1.5-2 cm from the front surface of the lower leg. For these measurements, use a compass, ruler or stop meters.

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

F.R. Bogdanov recommends measuring the longitudinal arch of the foot by constructing a triangle, the identification points of which are easily palpable. These points are: the head of the first metatarsal bone, the calcaneal tubercle and the apex of the inner ankle. By connecting these three points, a triangle is obtained, the base of which is the distance from the head of the first metatarsal bone to the calcaneal tuberosity. The calculation is carried out according to the height of the arch and the magnitude of the angles at the inner ankle and at the heel bone. Normally, the height of the arch is 55-60 mm, the angle at the ankle is 95 °, and the angle at the heel bone is 60 °. With a flat foot: the height of the arch is less than 55 mm, the angle at the ankle is 105-120 °, the angle at the heel bone is 55-50 °.

Determination of the degree of flat feet

To determine the degree of flat feet, an X-ray method of research is used. The calculation is based on the construction of a triangle, the vertices of which are the head of the metatarsal bone, the scaphoid bone and the tubercle of the calcaneus, and measuring the height of the arch and the magnitude of the angle at the scaphoid bone.

• With flat feet I degree: the height of the arch is less than 35 mm, the angle at the scaphoid is up to 140 °.
• With flat feet of the II degree: the height of the arch is 25 mm, the angle at the scaphoid is up to 155 °.
• With flat feet of the III degree: the arch is absent, the angle at the scaphoid is up to 170-175 °.

Determination of pronation of the hindfoot

Determination of pronation of the hindfoot (heel pronation) is carried out under axial load (the patient stands on the studied foot). An axis is drawn along the back surface of the lower leg along the midline of the Achilles tendon, going to the middle of the calcaneal tuberosity. Normally, the axis of the Achilles tendon and heel merges with the plumb line. The deviation of this axis outward from the vertical obtained with the help of a plumb line gives the pronation angle of the hind part of the deformed foot.

Forefoot abduction determination

The abduction of the forefoot (abduction) is determined by outlining the outer contours of the investigated foot. The outlines of the ankles are also outlined. After that, connect the most protruding parts of the contours of the ankles with a straight line. The axis of the normal foot passes through two points: through the middle of the tip of the second toe and the middle of the bimaleolar line. If we continue the axis of the foot towards the heel, then with the normal structure of the foot, most of the outlined heel is located inward from the axis of the foot. The axis of the foot forms an angle less than a right angle with the bimaleolar line. With a flat (pronated) foot, this angle is greater than a straight one, which indicates the presence of abduction of the forefoot; the value of the angle of deflection gives an idea of ​​the severity of abduction. The position of the axis on the outlined contour of the heel can be used to determine the degree of pronation of the hindfoot. All foot measurements must be taken symmetrically on both feet.

Definition of spinal curvature

Spinal curvature can occur in three planes:

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

Measurement of the lateral curvature of the spine is carried out in a standing position of the patient.

On the body, a line of spinous processes is marked from the upper cervical to the lower edge of the sacrum. A plumb line is lowered from the posterior edge of the large occipital foramen of the skull. In the absence of lateral curvature, the plumb line and spinous processes coincide. With a lateral curvature of the spine, the line of the spinous processes forms arcuate deviations from the vertical.

The magnitude of the lateral deviations of the line of spinous processes from the vertical straight line is measured in centimeters at the level of maximum curvature. Determine the points of intersection of the vertical and arcuate lines. The measurement data are transferred to a sheet of paper, on the same image, lines are plotted connecting the acromial processes of the scapula and the iliac crests. Normally, these lines are parallel to each other and perpendicular to the plumb line. The oblique standing of the pelvis and shoulder girdle violates this ratio.

Measurement of the anteroposterior curvature of the spine with a pronounced deformity (pointed hump) is performed using a protractor. With round humps and arcuate kyphosis, outline the contour with a pencil on paper or fix it with a wire or a plaster cast.

A.P. Skoblin, Yu.S. Lived, A.N. Dzhereley

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

A change in the length of a limb (more often in the direction of shortening) is a frequent and important sign of pathology of the musculoskeletal system. Limb shortening occurs as a result of dislocation or fracture, as a result of displacement of fragments, as a result of trauma, for example, an incorrectly fused fracture, joint contracture, in many diseases of the musculoskeletal system associated with a violation of trophism or the formation of primarily bone tissue.

As a general rule measurement is a comparison of symmetrical areas using symmetrical bony protrusions with the same position of the limbs or a neutral position of the trunk.

A qualitative determination of the change in length is carried out by comparing the level of the bone protrusions (Fig. 11-11-11-14). It must be remembered that sometimes the deformity of the pelvis, spine, shoulder girdle can level the difference in the length of the limbs. Elimination of deformation gives an idea of ​​the presence of shortening.

Rice. 11-11.Shortening of the shoulder determined by matching

Rice. 11-12.Shortening of the forearm as determined by comparison

Rice. 11-13.Shin shortening determined by matching

Rice. 11-14.Shortening of the left leg determined by matching

An accurate quantitative measurement is carried out using a measuring tape or special rulers. To clarify the localization of the pathology, a total measurement of the entire limb is carried out and its measurement by segments.

The length of the arm is usually measured from the acromial process of the scapula to the end of the third finger of the hand (Fig. 11-15). Bone landmarks for measuring the shoulder are the acromial process of the scapula and the olecranon, for the forearm - the olecranon and the styloid process of the ulna (Fig. 11-16, 11-17).

Rice. 11-15.Total arm length measurement

Rice. 11-16.

Rice. 11-17.Measuring arm length by segment

Rice. 11-18.Total leg length measurement

The total length of the leg is measured from the anterior superior iliac spine to the apex of the inner or outer ankle (Fig. 11-18). To measure the thigh, determine the distance from the apex of the greater trochanter to the articular gap of the knee joint (Fig. 11-19), to measure the lower leg - the distance from the slit of the knee joint to the external ankle.

The length of the shoulder girdle is determined by the distance from the sternal end of the clavicle to the acromial process of the scapula (Fig. 11-20).

Rice. 11-19.Leg length measurement by segments

Rice. 11-20.Determining the length of the shoulder girdle

When measuring the total length of a limb, a distinction is made between true (absolute or anatomical), relative and apparent (projection) change in length (Fig. 11-21). 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 with fractures, improper bone fusion, with violations of bone growth, etc. A relative change in length occurs when one segment is displaced relative to another, with a constant length of the limb segment itself, for example, with dislocations. Apparent, or projection, shortening is a shortening of the projection of a limb onto a straight plane with its length unchanged in segmental measurement. This type of shortening is more common with joint contractures.

2671 0

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

For example, acupuncture or local anesthesia of painful points of the periosteum is much more economical than massage of the periosteum, but when it comes to muscle attachment points, we prefer post-isometric relaxation whenever possible, because it is painless and in most cases patients can do it on their own.

The advantage of manipulations is their efficiency and speed of application.

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

We re-specify whether the methods of skin irritation were not used without a proper assessment of the patient's examination data, without information about the zone of hyperalgesia or muscle relaxation, if we do not find muscle tension, whether at least one manipulation was performed without establishing a blockage.

Naturally, a great loss of time in the appointment remedial gymnastics without prior detection of muscle coordination disorders. The correct pathogenetic diagnosis can be made only in those cases when the individual links of pathogenesis have been identified and their significance has been analyzed.

Only under this condition, after subsequent treatment, certain results can be expected. Thus, it is necessary, as in a neurological study, to systematically move from the periphery to the center, and then proceed to treatment according to the data obtained.

However, it happens that the results do not meet our expectations. The cause of this may be damage that causes increased nociceptive irritation and distorts the clinical picture, which the patient is not aware of.

It seems appropriate to us to dwell on such a concept as a crunch in the joint, which in most cases accompanies successful manipulation. It is known that this phenomenon can occur in healthy joints of the limbs and the spine, without any significance (for example, a crunch when stretching the fingers on the hand), and on the contrary, from our patients we know that painful sensations often arise in them after an ominous crack in joints in the sacrum or lumbar region, and we understand that this phenomenon should be regarded as an anamnestic sign.

During manipulative treatment, not always a successful reception is accompanied by a crunch in the joint, however, experience shows that in most cases this crunch indicates the success of the manipulation, and it is in these cases that a typical reflex phenomenon occurs (muscle hypotonia, a feeling of warmth, etc.). Even simple manual traction is especially effective if it causes a crunch in the joint.

With long-term observation, you can distinguish by ear the usual crunch, which can be caused in any joint, from the characteristic click that occurs when a blocked joint is released. Terrier believes that the usual crunching of a joint in the spine cannot be repeated over a short period of time.

When treating a blocked joint, it happens that the first careful manipulation does not give an effect, causing only a normal crunch in it, however, with repeated manipulation, a repeated characteristic click occurs. This difference in acoustic phenomenon indicates a significant difference between a conventional joint crunch and the process of clearing blockage.

What they have in common is that the structure that generates this acoustic phenomenon is most likely the joint itself. When we later consider the essence of joint blockage, this conclusion will play a role.

However, one should not overestimate the significance of this phenomenon: if, during a manipulative technique, he speaks of the success achieved, then during mobilization, in most cases, the blocking is removed without this phenomenon. We can go further into this problem - just discussing reversible joint blockages.

Methods for diagnosing the value of the functional difference in the length of the lower extremities (FRDNA)

Determining the value of FRDNA is a rather difficult task. Currently, a large number of methods and devices for determining this value are known, however, each of them has significant methodological and design flaws that do not allow determining the value of FRDNA with sufficient accuracy, and sometimes lead to false diagnostics.

Conventionally, all known methods for determining the value of the functional difference in the length of the lower extremitiescan be divided into three groups:

1. Visual inspection and palpation;
2. X-ray measurement techniques;
3. Anthropometry.

Visual inspection and palpation

According to the literature, the most common way to visually and palpate the presence of a functional difference in the length of the lower extremities is to determine the levels of the location of both halves of the pelvis. In a patient in an upright position, the doctor fixes the most high points on the iliac crests or their posterior superior spines and visually compares their levels. J. G. Travell and D. G. Simons believe that for examination the patient should stand with his back to the doctor (legs together, knees straightened).

The difference in leg length is determined by palpation of the iliac crests or their posterior superior spines. The patient should examine the spine for scoliosis in the thoracic and lumbar regions, the presence of an inclination of the axis of the shoulder girdle, as well as the position of the shoulder blades, which is determined by palpation of the standing levels of their lower angles.

For an approximate correction of a short leg, the authors suggest placing a pack of paper or a small magazine under it, while the patient should not experience any inconvenience. For one or two minutes, they maintain a conversation with the patient and set him up to relax and distribute his body weight on both legs.

When the short leg is lifted, the muscles that compensate for the difference in leg length are released from this function and relaxed. This makes it possible to more accurately compensate for the difference in leg length by additionally raising the short leg until the hips and shoulders are aligned horizontally and, most importantly, until the spine is aligned.

To be sure of the accuracy of the correction, the short leg is raised by another 1-2 mm, and if the correction was really accurate, then the pelvis, and sometimes the shoulder girdle, as a result of excessive lifting of the leg, tilt in the opposite direction from it.

The method described above for measuring the FRDNA value using a ream of paper or a magazine can hardly be taken seriously from the point of view of the accuracy of the data obtained.

According to V. J. Sicuranza and co-authors, during a visual examination, it is necessary to pay attention to the following symptoms. The arm on the side of the short leg is deflected from the body to the side, while the other arm is pressed against it. On the side of the long leg, the waist and hip protrusion are more pronounced.

On the side of the short leg, the gluteal fold is omitted. On the side on the side opposite to the bulge of the arc lumbar spine, there are significantly more skin folds. The authors also note that in some cases, to determine the presence of FRDNA, palpation is performed to compare the height of the greater trochanter of the femur.

An original method for determining the presence of a functional difference in the length of the lower extremities was proposed by R. Maigne. The patient is asked to swing forward - backward, first with one and then with the other. In this case, the short leg swings freely with a slight change in body position, while for swinging the long leg, the patient is forced to move half of the pelvis on this side up so that the foot does not touch the floor.

In cases where visual and palpatory data for the presence of FRDNA are contradictory, especially when scoliosis remains after leveling hip joints, one should look for a possible misalignment of the position of the sacrum, that is, a twisted pelvis.

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

The presence of FRDNA is known to lead to an asymmetry in the distribution of static and dynamic loads on each of the lower extremities. The leg, which has a large functional length, has a heavy load.

Technique of computed tomographic study of vertebral motor segments

CT examination of the PDS in order to diagnose degenerative-dystrophic pathology requires a technique of higher resolution than in the study of other organs. In particular, the pixel size must be at least 1 mm. A slice thickness of 4-5 mm is usually sufficient for adequate visualization of disc material, bone structures, dural sac and its contents. Thinner sections of 1.5-2 mm are used to clarify small details.

The position of the patient during the study is supine with the legs bent at the hip and knee joints, thereby smoothing the physiological lumbar lordosis.

The study begins with the production of an overview image - a lateral tomogram. Most authors recommend the technique of tilting the gantry (scanning device) according to the plane of the studied PDS. Setting the levels of slices and the angle of inclination of the gantry is performed on the lateral tomogram.

To visualize the spinal root along its entire intraspinal length, it is necessary that the sections are made from the level of the arch of the overlying vertebra to the level of the arch of the underlying vertebra. If it is necessary to obtain a reformed image, in this regard, only one PDS will be included in the reformation.

THEM. Danilov, V.N. Naboichenko