Gunshot wounds of the thigh in war rank first in frequency among wounds of all parts of the extremities. According to our statistics, the hip accounts for 49% of injuries to the lower limb. The surface of both thighs in relation to the entire body seems to be very large, and it is clear that the vulnerability of this surface will be the greatest. Among hip wounds, rifle bullet wounds predominate, accounting for 60%, the remaining 40% are wounds from shrapnel bullets and fragments of explosive shells.

While bullet wounds in most cases (up to 80%) are through and through, and sometimes there is even simultaneous wounding of both thighs, wounds from shrapnel, causing great tissue destruction, are more often blind; in this case, multiple fragments are often detected in the tissues.

This department of military field wounds is of greatest practical importance not only in terms of the frequency of hip wounds, but also in terms of the severity of their course and outcomes, and the issue of treating these wounds is one of the most important chapters of military field surgery.

The power of the muscle layers, separated by numerous fasciae, creates favorable conditions for the development of infection, especially anaerobic, in their depths. Damage to large vascular and nerve trunks sometimes immediately dooms the limb to necrosis, and such frequent gunshot fractures femur, this main and strongest lever of all the bones of the skeleton, sharply complicate the wound of soft tissues and cause the greatest impairment of the functions of the damaged limb.

Depending on the nature of the injury, the thigh can present varying degrees of severity. Starting from a simple through bullet wound of soft tissues, with slit-like entrance and exit holes, with slight bleeding, when the victim does not even immediately detect a wound and almost does not need any treatment, to severe crushing of almost the entire femur with simultaneous damage to one or more even two joints. Based on the experience of the first imperialist war, it can be noted that light wounds make up the majority in the general mass, and only in certain moments of intense artillery battle during hurricane artillery fire, hip wounds can be predominantly severe.

The type, properties and nature of gunshot wounds of the extremities are described above in the section “Features of wounds of the extremities.” It should be noted here that any of large vessels and the nerves of the thigh can be wounded by a direct blow from a projectile, but their damage more often occurs in a secondary way - from bone fragments, which acquire living force at the moment of injury and are thrown out. Therefore, the danger of injury from the outside of the thigh will always be greater, since bone fragments flying out to the exit hole are more likely to injure the main vessels of the thigh lying on its inner surface. Such wounds are often accompanied by severe bleeding and are more dangerous.

Among hip injuries, one should distinguish between injuries to its soft tissues and simultaneous injury to the femur.

• Which doctors should you contact if you have gunshot wounds of the lower limb?

What are Gunshot Wounds of the Lower Extremity?

Damage lower limbs bodies due to injury.

Pathogenesis (what happens?) during gunshot wounds of the lower extremities

With this category of injuries, many problems arise, the solution to which is not always simple. Wounds are accompanied by massive blood loss, wound healing conditions are worse than wounds on upper limb. Wounds are often complicated by infection. Closing the skin defect of the lower leg presents great difficulties. Difficulties arise when immobilizing the lower limb, especially with wounds in the proximal thigh. Massive wound discharge limits the use of coxite plaster casts. Traction treatment requires daily care, observation and regular x-ray monitoring.

Symptoms of Gunshot Wounds of the Lower Extremities

• Hip fractures

The most frequent symptoms gunshot hip fracture - deformation, pathological mobility, dysfunction, presence of bone fragments in the wound.

Limitation or impairment of the function of the injured limb can be caused by the wound itself, hemorrhage in the tendon sheaths and joints, damage to large nerve trunks and blood vessels, and impaired muscle tone as a result of the destruction of large muscle masses. A gunshot fracture can be accompanied by significant displacement of fragments at an angle, as well as shortening of the limb.

• Tibia fractures

This is a severe category of injuries, especially if there is a concomitant significant soft tissue defect and the tibia is exposed over a significant extent. It is necessary to excise tissue extremely sparingly, especially the skin, which subsequently often needs to be replaced using a free autograft. Practice shows that the flow wound process depends not so much on the scale of damage, but on the quality of the surgical treatment and postoperative patient management.

Gunshot wounds of the lower leg are also distinguished by the fact that the soft tissues surrounding the bone are often injured, including neurovascular formations, secondary bone fragments.

• Foot injuries

Relatively rarely, foot wounds are caused by bullets or shrapnel; more often, they are the result of explosions of anti-personnel or other types of mines.

Treatment of Gunshot Wounds of the Lower Extremities

• Hip fractures

At surgical treatment of a gunshot fracture of the femur wounds are much more complex than those on the shoulder or forearm. To ensure good access to all surfaces of the thigh, you can use the following technique: under anesthesia, a wire is passed through the tibial tuberosity and the entire thigh is suspended by it above the operating table. This provides good access for shaving, preparation of the surgical field and for surgical debridement. On the thigh, it is especially important to make a dissection over such a length that the excision does not leave non-viable tissue or loose bone fragments. You cannot do anything blindly; you must clearly see all the walls of the wound.

Having completed the surgical treatment of a gunshot fracture of the femur, the fragments are repositioned and compared with their fixation using a rod apparatus for transosseous osteosynthesis. The wound is left open (the skin is not sutured) to ensure complete drainage.

We should not forget about the method of skeletal traction, which can be indispensable for gunshot fractures, especially for proximal fractures. In some cases, you cannot refuse a plaster cast.

Intraosseous osteosynthesis for gunshot fractures of the femur is currently practically not performed due to the high percentage of purulent complications developing as a result, osteomyelitis, and high disability of the wounded.

The most rational method may be a two-stage treatment of a gunshot hip fracture, which consists of the following. During the initial surgical treatment of the wound and subsequent treatment, including the use of new drugs, conditions are created for the maximum fast healing wound, freeing it from rejected tissue. The thigh and lower leg may be in skeletal traction at this time. After the wound was completely cleaned and closed, the indicators returned to normal laboratory research, proceed to the second stage of treatment: the fracture is fixed using a plate for external osteosynthesis CITO-SOAN. Of course, this can be done in cases where the wound process proceeds without complications, there is no prolonged suppuration, formation of fistulas, osteitis, or osteomyelitis.

It is advisable to use a plate even if there is a bone defect, since in any case, subsequent lengthening of the limb will most likely be carried out at the expense of the tibia, and not at the expense of the thigh. This approach is advantageous in the sense that with technically correctly performed fixation of femoral fragments with a diaphyseal and even metadiaphyseal fracture, the wounded person can be raised to his feet 2 to a maximum of 3 weeks after the immersion osteosynthesis operation. In any case, the victim’s return to a normal lifestyle occurs much faster than when treated with plaster immobilization.

• Tibia fractures

After carefully performed surgical treatment and comparison of bone fragments, they are immobilized using an apparatus for extrafocal transosseous osteosynthesis. It should be assumed that in such situations this should be the method of choice, especially in cases where there is a large defect in the bone substance.

At small defect bone substance, the same tactics can be recommended as for a hip fracture: primary surgical treatment of the wound, fixation of the fracture using skeletal traction and after healing of the wound, final fixation of tibial fragments using the CITO-SOAN plate. It is possible to use transosseous osteosynthesis devices. Of course, in case of a gunshot fracture of the tibia, the entire arsenal of local and common funds, which were discussed in the “gunshot wound” section.

Foot injuries

Nevertheless, for bullet and shrapnel wounds of the foot, the principle of treatment should be approximately the same as for wounds of the hand. Restoration of destroyed anatomical structures and osteosynthesis is carried out by a specialist in a specialized medical institution. Therefore, it is advisable for such a victim to apply a bandage and take measures to prevent the development of wound complications, refer him to specialized hospital. It should be remembered that the frequency of purulent complications in foot injuries is high.

New methods for treating gunshot wounds

One of the most important tasks, if not the most important, in the treatment of gunshot wounds is the prevention of wound infection. This problem can be solved only with an integrated approach, when, along with full surgical treatment, the entire range of measures aimed at local sanitation of the wound, replenishment of blood loss, antibacterial therapy and immunocorrection, normalization of the body’s general immunological reactivity.

A new way to prevent suppuration and treat already developed suppuration in a gunshot wound is the use of low-intensity millimeter radiation. Millimeter radiation is capable of simulating control signals produced by a living organism, which take part in the correction of a number of homeostatic disorders, provoked, in particular, by such an extreme impact as a gunshot wound. For the first time this method was used to treat the wounded modern types firearms, including mine-explosive injuries.

For severe purulent complications accompanied by sepsis, in case of gas-forming wound infection, intravascular laser irradiation of blood is used to correct general and specific immunological reactivity. A portable installation of the LGN-S model can be used, emitting red monochromatic light with a wavelength of 632.8 nm, radiation flux density of 1.4-1.5 mW/cm, low-energy exposure.

To direct the beam into the lumen blood vessel A light guide with a diameter of 2 mm is used. The light guide is inserted through a large vein (subclavian, femoral). Required condition- preservation of blood flow in the vein. A continuous regimen is recommended for 2-2V2 hours, 5-8 daily sessions per course. The criterion is a favorable course of the purulent process. If there is no effect, the course of treatment is repeated after 4-5 days.

Heavy and extremely heavy clinical course in the wounded, it is most often accompanied by the inoculation of staphylococcus from the blood, and from the wounds - a variety of microflora, in particular Pseudomonas aeruginosa, Proteus, Escherichia coli, enterococcus, which are insensitive or not at all sensitive to many antibiotics.

Comparison of the results of treatment of wounded people with and without the use of laser endovascular blood irradiation proves its undoubted positive role. It should be borne in mind that the method is more effective if the compensatory capabilities of the body are preserved and there is no complete suppression of resistance and wound infection.

The method also differs in that the subjective state of the wounded significantly improves: after 2-3 sessions of laser endovascular therapy, as a rule, body temperature decreases, the condition of wounds improves, and peripheral blood counts normalize.

Along with its simplicity and safety, the high efficiency of the method in the most severe course of the wound process makes it indicated for use in military field surgery. The method ensures an increase in the effectiveness of simultaneously carried out methods of treating patients with purulent-septic complications.

They speak out various points view on the mechanism of action of red monochromatic light of a helium-neon laser. Many authors confirm the therapeutic effect of laser irradiation skin. At the same time, there is no information in the literature about the mechanism of the therapeutic effect of laser when used intravascularly. It can be assumed that with the endovascular use of low-energy laser radiation, the stimulating effect on indicators of the body’s natural resistance is associated with a nonspecific effect on regulatory mechanisms, which, under the influence of intoxication and injury, are not actively involved in mobilizing the body’s protective reserves. This hypothesis is supported by literature data and our research on the absence of a direct antimicrobial effect of monochromatic red light from a helium-neon laser. Upon appointment this method treatment, it is necessary to take into account that the stimulating effect of the laser against the background normal indicators reactivity can lead not to stimulation, but to its inhibition and worsening of the disease. The method requires further study and clarification of indications for use.

Replacement of defects in long tubular bones using the method of polylocal combined compression-distraction osteosynthesis. Replacement of defects in long tubular bones due to mine-explosive and gunshot wounds of limbs and joints is one of the most difficult problems of military field surgery. The currently used methods for replacing bone defects according to Ilizarov (monolocal sequential compression-distraction, bilocal compression-distraction and bilocal sequential distraction-compression osteosynthesis) provide favorable treatment outcomes in most cases. In some cases, replacement of defects in long tubular bones must be performed using polylocal combined compression-distraction osteosynthesis, the use of which can significantly reduce the time of rehabilitation treatment.

Replacement of bone defects is carried out after cupping inflammatory process in the area of ​​injury, on average after 1.5-2 months. The integrity of the bone is restored using the bi- and pililocal compression-distraction method. The choice of transosseous osteosynthesis technique depends on the size of the defect, the presence or absence of diastasis, and the location of the damage.

When the limb length is shortened by 11-15 cm, 2 and 3 osteotomies are performed to replace defects of the femur and tibia. With an average length of the tibia and femur of about 40 cm, this shortening amounts to 27.5-37.5% of the length of these segments. Thus, to replace bone defects, the surgeon always has the opportunity to form non-free bone grafts with a length of about 3-4 cm, which, according to angiographic studies, allows maintaining an adequate blood supply to the osteotomized bone fragments for the formation of a distraction regenerate. The minimum length of the osteotomized fragment must be no less than the diameter of the bone.

For the tibia this is 2.5-3 cm, for the femur - 3.0-3.5 cm. Based on these data and knowing the length of the bone fragments, it is not difficult to calculate the permissible amount of osteotomy to ensure restoration of the anatomical length of the tibia, femur or shoulder. The rate of distraction, however, should be somewhat less than that maintained when replacing bone defects using the method of bi-local transosseous osteosynthesis: on average 0.75 mm per day (0.25x3), and with minimal sizes of the osteotomized fragment - 0.5 mm (0.25x2). With the help of polylocal transosseous osteosynthesis, one strives not only to restore the weight-bearing ability of the limb and eliminate the existing bone defect, but also to minimize the treatment time.

• Polylocal compression-distraction osteosynthesis for polyfragmentary fractures tubular bones with a defect bone tissue. The fragments are isolated, the intermediate fragment of the tubular bone is osteosynthesized with two pairs of intersecting wires with the contacting fragment, the ends of the fragment are processed by performing transverse economical resection, osteotomy of the longest fragment is followed by movement of the osteotomized fragment in the defect. The damaged bone is fixed in a device of 4-5 rings. Advantage this method- the ability to combine fracture healing with restoration of the anatomical length of the damaged limb segment, which significantly reduces the treatment time for the wounded (2-2.5 times).
• Polylocal transosseous osteosynthesis with performing 2 and 3 osteotomies. Possible various options replacing bone defects using the specified method: by lengthening the proximal fragment, during which 2 osteotomies are performed while simultaneously, if possible, fixing the fracture zone; by lengthening the distal fragment in a similar manner; due to the lengthening of both proximal and distal fragments, along which one osteotomy is performed.
• Polylocal compression-distraction osteosynthesis for gunshot wounds joints and defects of long tubular bones. An arthrotomy is performed, economical resection of the articular ends, followed by fixation of the fragments with two pairs of intersecting wires to obtain arthrodesis. The operation is completed by treating the ends of bone fragments in the defect area and replacing it using one of the previously described methods. The period of limb immobilization with the apparatus and then with a plaster cast is determined in each specific case individually, taking into account the totality of clinical and radiological signs of completion of secondary ossification of the distraction regenerate. The device is removed after the transformation of the spongy regenerate into tubular bone begins. Radiologically during this period, very thin cortical plates are noted at the border of the regenerate with soft tissues, and the shadow of the regenerate in its intensity approaches the shadow of bone fragments. At this stage, the regenerate has a sufficient margin of safety that allows either to refuse to continue immobilization or to carry it out only for a very short time.

If the basic rules of treatment with external fixation devices are observed, the timing of the formation of a distraction regenerate depends mainly on the number of bone fragments produced by osteotomy. Thanks to the use of polylocal osteosynthesis, it is possible to reduce the time required for the formation of a distraction regenerate by more than 2 times when replacing extensive defects in long tubular bones. At the same time, the overall duration of treatment is reduced, which makes it possible to significantly reduce the costs of medical and social rehabilitation of the wounded.

Analgesic transcutaneous electrical stimulation in the system of rehabilitation treatment of patients with joint contractures after gunshot wounds of the extremities. Wounded people with the consequences of gunshot fractures of the extremities usually have persistent joint contractures that are difficult to treat. The reason for this is a number of features of the formation of joint contractures in gunshot fractures: myofasciotenodesis, which involves a much larger mass of tissue than is the case in non-gunshot fractures; pronounced cicatricial changes in the muscles as a consequence of the long course of the wound process; development infectious complications, progression of arthrogenic changes, affecting all elements of the bursal-ligamentous apparatus of the joint without exception. The only way to overcome the retraction of contracted tissues and restore a satisfactory range of motion in stiff joint- transosseous osteosynthesis.

There is a simple device for developing movements in the joints of the upper and lower extremities and some modifications of it. The device consists of 4 semi-arches, which are attached to 4 knitting needles, drawn in pairs in the frontal plane through the bones that form the joint. The semi-arcs, connected in pairs by stands, form two working links of the apparatus, which are connected to each other using two elastic springs that work for compression and torsion. The damper connection of paired segments of the apparatus makes it possible to painlessly distract the articular ends, thereby creating the necessary biomechanical conditions for subsequent flexion (extension) of the joint. The tightening of the springs between the links of the apparatus, providing the necessary degree of stretching of the joint space, is carried out by the patient himself, focusing on his sensations. Flexion at the joint is carried out by pushing apart two sagittally located semi-arches fixed to the front of the device with a screw device. Passive elimination of contracture with the help of such a device has only a temporary effect, which, after removing the elastic springs that fix the achieved position of flexion (extension), disappears after some time under the influence of contraction of the contracted muscles. Therefore, a method of alternating multi-stage elimination of joint stiffness is used, based on alternating passive flexion in the apparatus and the active development of movements in the joint by the patient himself after disconnecting the apparatus (imitation of its removal).

Treatment using this method aims, along with restoring movements in a stiff joint, to achieve normalization of muscle tone. Constant stretching of muscle fibers and ligaments in combination with massage has a beneficial effect on the elasticity of soft tissues, which in turn helps to increase the range of motion in the joint being developed. The treatment formula for this method is as follows:

2DRS + 6PSS + 6ASS + 6PSS + 6ASS,

where the numbers indicate the duration of each period in days, DRS - damper stretching of the joint; PSS - passive flexion of the joint with the help of an apparatus; ACC - active flexion of the joint performed by the patient himself.

The formula shows the approximate timing of each stage, which may vary depending on the nature of the contracture and the success of treatment. At the stage of independent development of movements in the joint (ASM), physiotherapeutic procedures are used: electrophoresis of novocaine on the joint area, general or segmental ultraviolet irradiation, magnetic therapy with elastic magnets with an induction of 30-35 mG for up to 40 minutes; There are 10-12 procedures per course. From the middle of rehabilitation treatment, aimed at maximizing the range of motion in the joint, electrophoresis of potassium iodide and lidase is prescribed. By this time, most wounded people have restored a satisfactory range of motion, usually 70-90°. As a rule, it is not possible to keep the limb in a position of extreme flexion or extension after the passive development of movements in the joint by the apparatus has ceased. The reason for this is the formed pain syndrome, which intensifies during the active development of movements in the joint and forces the patient to limit active movements. Application of reflex analgesia methods during classes physical therapy allows you to increase the effectiveness of the treatment and ensure the maximum achievable therapeutic effect in each specific case.

Pain relief is used during active development of movements in the joint immediately after massage of the muscles of the limb. Transcutaneous electrical nerve stimulation is used using a technique developed at the Central Research Institute of Reflexology. The novelty of the method lies in the fact that they simultaneously produce electroacupuncture effects on auricle with a frequency of 2 Hz and electroacupuncture stimulation of the injured limb with a frequency of 10 Hz and the location of the stimulating electrode proximal to the site of injury. With such combined stimulation, both central and peripheral mechanisms of the antinociceptive system are activated. The analgesic effect is enhanced if electrical stimulation of the earlobes begins 10 days before 15 minutes before the start of physical therapy classes. This is explained by the fact that for the formation of opiate endorphins in the brain tissue and their entry into the blood, a certain time is required for each patient, on average 10-15 minutes. The magnitude of the current during transcutaneous electrical stimulation in patients they select it themselves, focusing on the appearance of subpainful sensations.

Reflex analgesia in the system of restorative treatment of persistent joint contractures after gunshot fractures helps to consolidate the satisfactory range of motion in the joint achieved with the help of the device, reduces the time of hospital treatment and ensures rapid rehabilitation of patients. The poor outcome of treatment is explained by the phenomena of severe deforming arthrosis.

Gunshot wounds of the soft tissues of the thigh are accompanied by vascular damage. With gunshot fractures of the femur, bone damage and changes in surrounding tissues are often very significant and extend far beyond the wound canal (Fig. 9).

Rice. 9. Diagram of a gunshot comminuted femoral fracture (according to A.V. Smolyannikov): 1 - area of ​​pinpoint hemorrhages in the bone marrow; 2 - small bone fragments in the medullary canal and soft tissues; 3 - zone of hemorrhagic bone marrow infiltration; 4 - zone of hemorrhagic infiltration of the Haversian canals; 5 - inlet; 6 - paraosseous and intermuscular hematoma; 7 - soft tissue crush zone; 8 - bone fragments torn from the periosteum.

Along with the bone, large vessels and nerve trunks are sometimes damaged. The most common complications were secondary bleeding and anaerobic infection, shock; in a later period - gunshot osteomyelitis and sepsis, pseudarthrosis, contractures.

Staged treatment of gunshot fractures during the Great Patriotic War included measures aimed at combating shock and blood loss; infection prevention and control was carried out. First aid on the battlefield consisted of stopping bleeding and immobilizing the limb using improvised means; at the stages of the first medical care Immobilization was performed using standard splints. At the stage where qualified surgical care is provided, it is important to identify a group of hip wounded people in need of urgent surgical intervention(bleeding, suspected anaerobic infection), and, if possible, perform surgical treatment of wounds. Therapeutic immobilization can be performed only at the stage where specialized care is provided. Provided that the wounded person can be detained at this stage for at least 4-5 days, the most appropriate type of therapeutic immobilization is a deaf, unlined plaster cast (B. A. Petrov) from the lower sections chest(at the level of the nipples) to the toes, applied after complete treatment of the wound (primary or secondary), reposition of fragments and administration of antibiotics. The successive stages of applying a plaster cast with a pelvic girdle on an orthopedic table are shown in Fig. 10-12. Contraindications to applying a plaster cast: suspicion of anaerobic infection, secondary bleeding, circulatory disorders after ligation of the femoral artery, burns.

Rice. 10-12. Stages of applying a plaster cast.

Careful monitoring of the general condition of the wounded allows for timely identification of complications. Deterioration in health, pain in the wound area, increased temperature, bad dream and appetite, chills in the evenings, changes in blood are indications for opening or removing the plaster cast and inspecting the wound. If necessary, repeat surgical treatment is performed: widening the wound, removing necrotic tissue, foreign bodies, free bone fragments, opening and draining the leaks and creating counter-openings. If symptoms of an anaerobic infection are detected, the question of indications for urgent amputation should be decided (depending on the location, spread and nature of the infection).

Depending on the general condition In the case of a wounded person with significant displacement of fragments or danger associated with bleeding, skeletal traction is used. After eliminating complications and comparing the fragments, a plaster cast is applied again. In some cases, with a calm course of the wound process and conservative treatment In a wounded person with a plaster cast applied, there is a significant divergence of the fragments, and therefore there may be a need for intraosseous fixation of the fragments. The insertion of a metal pin during this operation, as a rule, is performed not retrograde, but from the side of the trochanteric fossa.

Complications after gunshot hip fractures most often occur due to late admission of the wounded person to medical institution, poor immobilization of the limb, the impossibility of surgical treatment of the wound and measures to combat shock, blood loss, etc.

Mortality from hip wounds during the Great Patriotic War was significantly higher than from gunshot wounds to other areas of the lower limb. Causes of death: anaerobic infection, sepsis, shock, bleeding, a combination of these complications, osteomyelitis, etc. See also Wounds, wounds.

Gunshot wounds of the lower limb

What are Gunshot Wounds of the Lower Extremity -

Damage to the lower extremities of the body due to injury.

Pathogenesis (what happens?) during gunshot wounds of the lower extremities:

With this category of injuries, many problems arise, the solution to which is not always simple. Wounds are accompanied by massive blood loss, wound healing conditions are worse than wounds on the upper limb. Wounds are often complicated by infection. Closing the skin defect of the lower leg presents great difficulties. Difficulties arise when immobilizing the lower limb, especially with wounds in the proximal thigh. Massive wound discharge limits the use of coxite plaster casts. Traction treatment requires daily care, observation and regular x-ray monitoring.

Symptoms of Gunshot Wounds of the Lower Extremities:

• Hip fractures

The most common symptoms of a gunshot hip fracture are deformation, pathological mobility, dysfunction, and the presence of bone fragments in the wound.

Limitation or impairment of the function of the injured limb can be caused by the wound itself, hemorrhage in the tendon sheaths and joints, damage to large nerve trunks and blood vessels, and impaired muscle tone as a result of the destruction of large muscle masses. A gunshot fracture can be accompanied by significant displacement of fragments at an angle, as well as shortening of the limb.

• Tibia fractures

This is a severe category of injuries, especially if there is a concomitant significant soft tissue defect and the tibia is exposed over a significant extent. It is necessary to excise tissue extremely sparingly, especially the skin, which subsequently often needs to be replaced using a free autograft. Practice shows that the course of the wound process depends not so much on the scale of the damage, but on the quality of the surgical treatment performed and postoperative management of the patient.

Gunshot wounds of the lower leg are also distinguished by the fact that in them the soft tissues surrounding the bone, including neurovascular formations, are often injured by secondary bone fragments.

• Foot injuries

Relatively rarely, foot wounds are caused by bullets or shrapnel; more often, they are the result of explosions of anti-personnel or other types of mines.

Treatment of gunshot wounds of the lower extremities:

• Hip fractures

At surgical treatment of a gunshot fracture of the femur wounds are much more complex than those on the shoulder or forearm. To ensure good access to all surfaces of the thigh, you can use the following technique: under anesthesia, a wire is passed through the tibial tuberosity and the entire thigh is suspended by it above the operating table. This provides good access for shaving, preparation of the surgical field and for surgical debridement. On the thigh, it is especially important to make a dissection over such a length that the excision does not leave non-viable tissue or loose bone fragments. You cannot do anything blindly; you must clearly see all the walls of the wound.

Having completed the surgical treatment of a gunshot fracture of the femur, the fragments are repositioned and compared with their fixation using a rod apparatus for transosseous osteosynthesis. The wound is left open (the skin is not sutured) to ensure complete drainage.

We should not forget about the method of skeletal traction, which can be indispensable for gunshot fractures, especially for proximal fractures. In some cases, you cannot refuse a plaster cast.

Intraosseous osteosynthesis for gunshot fractures of the femur is currently practically not performed due to the high percentage of purulent complications developing as a result, osteomyelitis, and high disability of the wounded.

The most rational method may be a two-stage treatment of a gunshot hip fracture, which consists of the following. During the initial surgical treatment of the wound and subsequent treatment, including the use of new drugs, conditions are created for the fastest possible healing of the wound and freeing it from rejected tissue. The thigh and lower leg may be in skeletal traction at this time. After the wound is completely cleaned and closed, laboratory test parameters have returned to normal, they proceed to the second stage of treatment: the fracture is fixed using a plate for external osteosynthesis CITO-SOAN. Of course, this can be done in cases where the wound process proceeds without complications, there is no prolonged suppuration, formation of fistulas, osteitis, or osteomyelitis.

It is advisable to use a plate even if there is a bone defect, since in any case, subsequent lengthening of the limb will most likely be carried out at the expense of the tibia, and not at the expense of the thigh. This approach is advantageous in the sense that with technically correctly performed fixation of femoral fragments with a diaphyseal and even metadiaphyseal fracture, the wounded person can be raised to his feet 2 to a maximum of 3 weeks after the immersion osteosynthesis operation. In any case, the victim’s return to a normal lifestyle occurs much faster than when treated with plaster immobilization.

• Tibia fractures

After carefully performed surgical treatment and comparison of bone fragments, they are immobilized using an apparatus for extrafocal transosseous osteosynthesis. It should be assumed that in such situations this should be the method of choice, especially in cases where there is a large defect in the bone substance.

In case of a small defect in the bone substance, the same tactics can be recommended as for a femoral fracture: primary surgical treatment of the wound, fixation of the fracture using skeletal traction and after healing of the wound, final fixation of the tibia fragments using the CITO-SOAN plate. It is possible to use transosseous osteosynthesis devices. Of course, in case of a gunshot fracture of the leg, the entire arsenal of local and general remedies discussed in the section “gunshot wound” should be used.

Foot injuries

Nevertheless, for bullet and shrapnel wounds of the foot, the principle of treatment should be approximately the same as for wounds of the hand. Restoration of destroyed anatomical structures and osteosynthesis is carried out by a specialist in a specialized medical institution. Therefore, it is advisable for such a victim to apply a bandage and take measures to prevent the development of wound complications, and send him to a specialized hospital. It should be remembered that the frequency of purulent complications in foot injuries is high.

New methods for treating gunshot wounds

One of the most important tasks, if not the most important, in the treatment of gunshot wounds is the prevention of wound infection. This problem can be solved only with an integrated approach, when, along with full surgical treatment, a whole range of measures is carried out aimed at local sanitation of the wound, replenishment of blood loss, antibacterial therapy and immunocorrection, and normalization of the general immunological reactivity of the body.

A new way to prevent suppuration and treat already developed suppuration in a gunshot wound is the use of low-intensity millimeter radiation. Millimeter radiation is capable of simulating control signals produced by a living organism, which take part in the correction of a number of homeostatic disorders, provoked, in particular, by such an extreme impact as a gunshot wound. For the first time, this method was used to treat patients wounded by modern types of firearms, including those with mine-explosive injuries.

In case of severe purulent complications accompanied by sepsis or gas-forming wound infection, intravascular laser irradiation of blood is used to correct general and specific immunological reactivity. A portable installation of the LGN-Sh model can be used, emitting red monochromatic light with a wavelength of 632.8 nm, radiation flux density of 1.4-1.5 mW/cm, low-energy exposure.

A light guide with a diameter of 2 mm is used to direct the beam into the lumen of the blood vessel. The light guide is inserted through a large vein (subclavian, femoral). A prerequisite is maintaining blood flow in the vein. A continuous regimen is recommended for 2-2V2 hours, 5-8 daily sessions per course. The criterion is a favorable course of the purulent process. If there is no effect, the course of treatment is repeated after 4-5 days.

A severe and extremely severe clinical course in the wounded is most often accompanied by the culture of staphylococcus from the blood, and from the wounds - a variety of microflora, in particular blue pus, Proteus, Escherichia coli, enterococcus, which are insensitive or not at all sensitive to many antibiotics.

Comparison of the results of treatment of wounded people with and without the use of laser endovascular blood irradiation proves its undoubted positive role. It should be borne in mind that the method is more effective if the compensatory capabilities of the body are preserved and there is no complete suppression of resistance and wound infection.

The method also differs in that the subjective state of the wounded significantly improves: after 2-3 sessions of laser endovascular therapy, as a rule, body temperature decreases, the condition of wounds improves, and peripheral blood counts normalize.

Along with its simplicity and safety, the high efficiency of the method in the most severe course of the wound process makes it indicated for use in military field surgery. The method ensures an increase in the effectiveness of simultaneously carried out methods of treating patients with purulent-septic complications.

Various points of view have been expressed about the mechanism of action of red monochromatic light from a helium-neon laser. Many authors confirm the therapeutic effect of laser irradiation of the skin. At the same time, there is no information in the literature about the mechanism of the therapeutic effect of laser when used intravascularly. It can be assumed that with the endovascular use of low-energy laser radiation, the stimulating effect on indicators of the body’s natural resistance is associated with a nonspecific effect on regulatory mechanisms, which, under the influence of intoxication and injury, are not actively involved in mobilizing the body’s protective reserves. This hypothesis is supported by literature data and our research on the absence of a direct antimicrobial effect of monochromatic red light from a helium-neon laser. When prescribing this method of treatment, it is necessary to take into account that the stimulating effect of a laser against the background of normal reactivity indicators can lead not to stimulation, but to its inhibition and worsening of the disease. The method requires further study and clarification of indications for use.

Replacement of defects in long tubular bones using the method of polylocal combined compression-distraction osteosynthesis. Replacement of defects in long tubular bones due to mine-explosive and gunshot wounds of limbs and joints is one of the most difficult problems of military field surgery. The currently used methods for replacing bone defects according to Ilizarov (monolocal sequential compression-distraction, bilocal compression-distraction and bilocal sequential distraction-compression osteosynthesis) provide favorable treatment outcomes in most cases. In some cases, replacement of defects in long tubular bones must be performed using polylocal combined compression-distraction osteosynthesis, the use of which can significantly reduce the time of rehabilitation treatment.

Replacement of bone defects is carried out after the inflammatory process in the wound area has stopped, on average after 1.5-2 months. The integrity of the bone is restored using the bi- and pililocal compression-distraction method. The choice of transosseous osteosynthesis technique depends on the size of the defect, the presence or absence of diastasis, and the location of the damage.

When the limb length is shortened by 11-15 cm, 2 and 3 osteotomies are performed to replace defects of the femur and tibia. With an average length of the tibia and femur of about 40 cm, this shortening amounts to 27.5-37.5% of the length of these segments. Thus, to replace bone defects, the surgeon always has the opportunity to form non-free bone grafts with a length of about 3-4 cm, which, according to angiographic studies, allows maintaining an adequate blood supply to the osteotomized bone fragments for the formation of a distraction regenerate. The minimum length of the osteotomized fragment must be no less than the diameter of the bone.

For the tibia this is 2.5-3 cm, for the femur - 3.0-3.5 cm. Based on these data and knowing the length of the bone fragments, it is not difficult to calculate the permissible amount of osteotomy to ensure restoration of the anatomical length of the tibia, femur or shoulder. The rate of distraction, however, should be somewhat less than that maintained when replacing bone defects using the method of bi-local transosseous osteosynthesis: on average 0.75 mm per day (0.25x3), and with minimal sizes of the osteotomized fragment - 0.5 mm (0.25x2). With the help of polylocal transosseous osteosynthesis, one strives not only to restore the weight-bearing ability of the limb and eliminate the existing bone defect, but also to minimize the treatment time.

• Polylocal compression-distraction osteosynthesis for polyfragmentary fractures tubular bones with a bone tissue defect. The fragments are isolated, the intermediate fragment of the tubular bone is osteosynthesized with two pairs of intersecting wires with the contacting fragment, the ends of the fragment are processed by performing transverse economical resection, osteotomy of the longest fragment is followed by movement of the osteotomized fragment in the defect. The damaged bone is fixed in a device of 4-5 rings. The advantage of this method is the ability to combine fracture healing with restoration of the anatomical length of the damaged limb segment, which significantly reduces the treatment time for the wounded (by 2-2.5 times).
• Polylocal transosseous osteosynthesis with performing 2 and 3 osteotomies. Various options for replacing bone defects using the specified method are possible: by lengthening the proximal fragment, along which 2 osteotomies are performed while simultaneously, if possible, fixing the fracture zone; by lengthening the distal fragment in a similar manner; due to the lengthening of both proximal and distal fragments, along which one osteotomy is performed.
• Polylocal compression-distraction osteosynthesis for gunshot wounds joints and defects of long tubular bones. An arthrotomy is performed, economical resection of the articular ends, followed by fixation of the fragments with two pairs of intersecting wires to obtain arthrodesis. The operation is completed by treating the ends of bone fragments in the defect area and replacing it using one of the previously described methods. The period of limb immobilization with the apparatus and then with a plaster cast is determined in each specific case individually, taking into account the totality of clinical and radiological signs of completion of secondary ossification of the distraction regenerate. The device is removed after the transformation of the spongy regenerate into tubular bone begins. Radiologically during this period, very thin cortical plates are noted at the border of the regenerate with soft tissues, and the shadow of the regenerate in its intensity approaches the shadow of bone fragments. At this stage, the regenerate has a sufficient margin of safety that allows either to refuse to continue immobilization or to carry it out only for a very short time.

If the basic rules of treatment with external fixation devices are observed, the timing of the formation of a distraction regenerate depends mainly on the number of bone fragments produced by osteotomy. Thanks to the use of polylocal osteosynthesis, it is possible to reduce the time required for the formation of a distraction regenerate by more than 2 times when replacing extensive defects in long tubular bones. At the same time, the overall duration of treatment is reduced, which makes it possible to significantly reduce the costs of medical and social rehabilitation of the wounded.

Analgesic transcutaneous electrical stimulation in the system of rehabilitation treatment of patients with joint contractures after gunshot wounds of the extremities. Wounded people with the consequences of gunshot fractures of the extremities usually have persistent joint contractures that are difficult to treat. The reason for this is a number of features of the formation of joint contractures in gunshot fractures: myofasciotenodesis, which involves a much larger mass of tissue than is the case in non-gunshot fractures; pronounced cicatricial changes in the muscles as a consequence of the long course of the wound process; development of infectious complications, progression of arthrogenic changes, affecting all elements of the bursal-ligamentous apparatus of the joint without exception. The only way to overcome the retraction of contracted tissues and restore a satisfactory range of motion in a stiff joint is transosseous osteosynthesis.

There is a simple device for developing movements in the joints of the upper and lower extremities and some modifications of it. The device consists of 4 semi-arches, which are attached to 4 knitting needles, drawn in pairs in the frontal plane through the bones that form the joint. The semi-arcs, connected in pairs by stands, form two working links of the apparatus, which are connected to each other using two elastic springs that work for compression and torsion. The damper connection of paired segments of the apparatus makes it possible to painlessly distract the articular ends, thereby creating the necessary biomechanical conditions for subsequent flexion (extension) of the joint. The tightening of the springs between the links of the apparatus, providing the necessary degree of stretching of the joint space, is carried out by the patient himself, focusing on his sensations. Flexion at the joint is carried out by pushing apart two sagittally located semi-arches fixed to the front of the device with a screw device. Passive elimination of contracture with the help of such a device has only a temporary effect, which, after removing the elastic springs that fix the achieved position of flexion (extension), disappears after some time under the influence of contraction of the contracted muscles. Therefore, a method of alternating multi-stage elimination of joint stiffness is used, based on alternating passive flexion in the apparatus and the active development of movements in the joint by the patient himself after disconnecting the apparatus (imitation of its removal).

Treatment using this method aims, along with restoring movements in a stiff joint, to achieve normalization of muscle tone. Constant stretching of muscle fibers and ligaments in combination with massage has a beneficial effect on the elasticity of soft tissues, which in turn helps to increase the range of motion in the joint being developed. The treatment formula for this method is as follows:

2DRS + 6PSS + 6ASS + 6PSS + 6ASS,

where the numbers indicate the duration of each period in days, DRS - damper stretching of the joint; PSS - passive flexion of the joint with the help of an apparatus; ACC - active flexion of the joint performed by the patient himself.

The formula shows the approximate timing of each stage, which may vary depending on the nature of the contracture and the success of treatment. At the stage of independent development of movements in the joint (ASM), physiotherapeutic procedures are used: electrophoresis of novocaine on the joint area, general or segmental ultraviolet irradiation, magnetic therapy with elastic magnets with an induction of 30-35 mG for up to 40 minutes; There are 10-12 procedures per course. From the middle of rehabilitation treatment, aimed at maximizing the range of motion in the joint, electrophoresis of potassium iodide and lidase is prescribed. By this time, most wounded people have restored a satisfactory range of motion, usually 70-90°. As a rule, it is not possible to keep the limb in a position of extreme flexion or extension after the passive development of movements in the joint by the apparatus has ceased. The reason for this is the formed pain syndrome, which intensifies during the active development of movements in the joint and forces the patient to limit active movements. The use of reflex analgesia methods during physical therapy exercises makes it possible to increase the effectiveness of the treatment and ensure the maximum therapeutic effect achievable in each specific case.

Pain relief is used during active development of movements in the joint immediately after massage of the muscles of the limb. Transcutaneous electrical nerve stimulation is used using a technique developed at the Central Research Institute of Reflexology. The novelty of the method lies in the fact that they simultaneously produce electroacupuncture effects on the auricle with a frequency of 2 Hz and electroacupuncture stimulation of the damaged limb with a frequency of 10 Hz and the location of the stimulating electrode proximal to the site of injury. With such combined stimulation, both central and peripheral antinociceptive mechanisms are activated system. The analgesic effect is enhanced if electrical stimulation of the earlobes begins 10-15 minutes before the start of physical therapy. This is explained by the fact that for the formation of opiate endorphins in the brain tissue and their entry into the blood, a certain time is required for each patient, on average 10-15 minutes Patients select the current value during transcutaneous electrical stimulation themselves, focusing on the appearance of subpainful sensations.

Reflex analgesia in the system of restorative treatment of persistent joint contractures after gunshot fractures helps to consolidate the satisfactory range of motion in the joint achieved with the help of the device, reduces the time of hospital treatment and ensures rapid rehabilitation of patients. The poor outcome of treatment is explained by the phenomena of severe deforming arthrosis.

Which doctors should you contact if you have gunshot wounds of the lower limb:

• Traumatologist
• Surgeon

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Other diseases from the group Trauma, poisoning and some other consequences of external causes:

Gunshot wounds of the soft tissues of the thigh accompanied by vascular damage. With gunshot fractures of the femur, bone damage and changes in surrounding tissues are often very significant and extend far beyond the wound canal (Fig. 9).

Rice. 9. Diagram of a gunshot comminuted femoral fracture (according to A.V. Smolyannikov): 1 - area of ​​pinpoint hemorrhages in the bone marrow; 2 - small bone fragments in the medullary canal and soft tissues; 3 - zone of hemorrhagic bone marrow infiltration; 4 - zone of hemorrhagic infiltration of the Haversian canals; 5 - inlet; 6 - paraosseous and intermuscular hematoma; 7 - soft tissue crush zone; 8 - bone fragments torn from the periosteum.

Along with the bone, large vessels and nerve trunks are sometimes damaged. The most common complications were secondary bleeding and anaerobic infection, shock; in a later period - gunshot osteomyelitis and sepsis, pseudarthrosis, contractures.
Staged treatment of gunshot fractures during the Great Patriotic War included measures aimed at combating shock and blood loss; infection prevention and control was carried out. First aid on the battlefield consisted of stopping bleeding and immobilizing the limb using improvised means; At the stages of first medical aid, immobilization was performed with standard splints. At the stage where qualified surgical care is provided, it is important to identify a group of wounded hip in need of urgent surgical intervention (bleeding, suspected anaerobic infection), and, if possible, perform surgical treatment of wounds. Therapeutic immobilization can be performed only at the stage where specialized care is provided. Provided that the wounded person can be detained at this stage for at least 4-5 days, the most appropriate type of therapeutic immobilization is a solid, unlined plaster cast bandage(B.A. Petrov) from the lower parts of the chest (at the level of the nipples) to the toes, applied after complete treatment of the wound (primary or secondary), reposition of fragments and administration of antibiotics. The successive stages of applying a plaster cast with a pelvic girdle on an orthopedic table are shown in Fig. 10-12. Contraindications to applying a plaster cast: suspicion of anaerobic infection, secondary bleeding, circulatory disorders after ligation of the femoral artery, burns.

Rice. 10-12. Stages of applying a plaster cast.

Careful monitoring of the general condition of the wounded allows for timely identification of complications. Deterioration in health, the appearance of pain in the wound area, increased temperature, poor sleep and appetite, chills in the evenings, changes in the blood are indications for opening or removing the plaster cast and revising the wound. If necessary, repeat surgical treatment is performed: widening the wound, removing necrotic tissue, foreign bodies, free bone fragments, opening and draining the leaks and creating counter-openings. If symptoms of an anaerobic infection are detected, the question of indications for urgent amputation should be decided (depending on the location, spread and nature of the infection).
Depending on the general condition of the wounded person, if there is significant displacement of fragments or danger associated with bleeding, skeletal traction is used. After eliminating complications and comparing the fragments, a plaster cast is applied again. In some cases, with a calm course of the wound process and conservative treatment of the wounded person with the application of a plaster cast, a significant divergence of fragments is observed, and therefore there may be a need for intraosseous fixation of the fragments. The insertion of a metal pin during this operation, as a rule, is performed not retrograde, but from the side of the trochanteric fossa.
Complications after gunshot fractures of the femur most often arise due to late admission of the wounded person to a medical institution, poor immobilization of the limb, the impossibility of surgical treatment of the wound and measures to combat shock, blood loss, etc.
Mortality from hip wounds during the Great Patriotic War was significantly higher than from gunshot wounds to other areas of the lower limb. Causes of death: anaerobic infection, sepsis, shock, bleeding, a combination of these complications, osteomyelitis, etc. See also Wounds, wounds.