Distal phalanx of the thumb. Distal phalanges of the fingers. Anatomy and structure of the finger

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Of the phalanges, the nail is most often damaged, then the proximal and middle, often without displacement of the fragments. For marginal fractures, immobilization with a plaster splint lasts 1-1 1/2 weeks; for fractures of the nail phalanx, the nail acts as a splint.

Reposition of fragments is carried out by traction along the axis of the finger while simultaneously giving it a functionally advantageous position. Immobilization is carried out with two plaster splints (palmar and dorsal) from the tip of the finger to the upper third of the forearm (Fig. 1). For intra-articular fractures, shorter periods are required (up to 2 weeks), for periarticular fractures - up to 3 weeks, for diaphyseal fractures - up to 4-5 weeks. Fractures of the proximal phalanx heal faster than fractures of the middle phalanx.

Rice. 1. Therapeutic immobilization for fractures of the phalanges of the fingers: a - plaster splint; b - Böhler splint; c - rear modeled tire

Rehabilitation - 1-3 weeks.

Surgical treatment indicated for fractures of the metacarpal bones and phalanges with a tendency to secondary displacement. The fragments are compared and fixed with pins percutaneously (Fig. 2). Immobilization is carried out with a plaster splint on the palmar surface for 4 weeks. The needles are removed after 3-4 weeks. For intra-articular and periarticular fractures of the phalanges with displacement of fragments, a distraction device is used.

Rice. 2. Transosseous fixation with wires of fractures and fracture-dislocations of the phalanges of the fingers: a - with wires (options); b - distraction external device

Damage to the ligaments of the finger joints

Causes. Damage to the lateral ligaments occurs as a result of a sharp deviation of the finger at the joint level (impact, fall, “breaking off”). More often, the ligaments are partially torn, but a complete rupture leads to instability of the joint. The ligaments of the proximal interphalangeal joints and the first metacarpophalangeal joint are mainly damaged.

Signs: pain and swelling in the joint area, limitation of movements, lateral mobility. The diagnosis is clarified by pinpoint palpation with a button probe or the end of a match. To exclude avulsion of a bone fragment, it is necessary to take radiographs in two projections. When the ulnar collateral ligament of the metacarpophalangeal joint of the first finger is ruptured, the swelling may be insignificant. Characterized by pain when abducting the finger to the radial side and decreased grip strength. The ligament may be damaged along its length, or it may be torn from its attachment to the proximal phalanx.

Treatment. Local cooling, immobilization of the finger in a half-bent position on a cotton-gauze roll. Application of a simulated plaster splint along the palmar surface of the finger to the middle third of the forearm. Flexion at the joint to an angle of 150°. UHF therapy is prescribed as a decongestant.

The period of immobilization is 10-14 days, then light thermal procedures and exercise therapy.

The first finger is immobilized in a position of slight flexion and ulnar adduction for a period of 3-4 weeks. In cases of complete rupture of the ligament or its separation, early surgical treatment (suture, plastic surgery) in a specialized setting is indicated. medical institution. After the operation - immobilization with a plaster splint also for 3-4 weeks. Rehabilitation - 2-3 weeks.

Working capacity is restored after 1-1 1/2 months.

Damage to the extensor tendons of the fingers

Features of the anatomy are presented in Fig. 3.

Rice. 3. Scheme of the structure of the dorsal aponeurosis: a - common extensor tendon; b — tendon of the interosseous muscles; c — tendon of the lumbrical muscles; d - spiral fibers; d - retinacular ligaments; e - triangular ligaments; g - central tape; h - side tapes; and - a portion of the aponeurosis to the base of the proximal phalanx; j - medial stripes of the tendons of the interosseous and lumbrical muscles; l - middle portion of aponeurosis; m - lateral stripes of the tendons of the interosseous and lumbrical muscles; n - lateral portions of the aponeurosis; o - the final part of the tendon-aponeurotic stretch; n - transverse intermetacarpal ligaments; p - transverse portion of the reticular ligament

Injuries to the extensor tendons of the fingers and hand account for 0.6-0.8% of all fresh injuries. From 9 to 11.5% of patients are hospitalized. Open injuries account for 80.7%, closed - 19.3%.

Causes of open extensor tendon injuries:

• incised wounds (54.4%);
• bruised wounds (23%);
• lacerations (19,5 %);
• gunshot wounds and thermal injuries (5%).

Causes of closed extensor tendon injuries:

• traumatic - as a result of an indirect mechanism of injury;
• spontaneous - arise as a result of degenerative-dystrophic changes in the tendons and unusual load on the fingers.

Subcutaneous rupture of the tendon of the long extensor of the first finger was described in 1891 by Sander under the name “drummers' paralysis.” In army drummers, with prolonged stress on the hand in the dorsiflexion position, chronic tenosynovitis develops, causing degeneration of the tendon and, as a consequence, its spontaneous rupture. Another cause of subcutaneous rupture of the tendon of the long extensor of the first finger is microtrauma after a fracture of the radius in a typical place.

Diagnostics fresh open injuries of the extensor tendons do not present any particular difficulties. The localization of wounds on the dorsum of the fingers and hand should alert the doctor, who will pay special attention to the study of motor function. Damage to the extensor tendons, depending on the area of ​​damage, is accompanied by characteristic disorders functions (Fig. 4).

Rice. 4.

1st zone - zone of the distal interphalangeal joint to the upper third of the middle phalanx - loss of the function of extension of the distal phalanx of the finger.

Treatment surgical - suturing the extensor tendon. If the extensor tendon is damaged at the level of its attachment to the distal phalanx, a transosseous suture is used. After surgery, the distal phalanx is fixed in the extension position with a wire passed through the distal interphalangeal joint for 5 weeks.

2nd zone - the zone of the base of the middle phalanx, the proximal interphalangeal joint and the main phalanx - loss of the function of extension of the middle phalanx of the II-V fingers. If the central extensor fascicle is damaged, its lateral fascicles shift to the palmar side and begin to extend the distal phalanx, the middle phalanx takes a flexion position, and the distal phalanx takes an extension position.

Treatment surgical - suturing the central bundle of the extensor tendon, restoring the connection of the lateral bundles with the central one. If all three bundles of the extensor apparatus are damaged, a primary suture is applied with separate restoration of each bundle.

After surgery - immobilization for 4 weeks. After applying a suture to the tendon and immobilization for the period of fusion, an extension contracture of the joints develops, which requires long-term rehabilitation.

3rd zone - the zone of the metacarpophalangeal joints and metacarpus - loss of the function of extension of the main phalanx (Fig. 5).

Rice. 5.

Treatment surgical - suturing the extensor tendon, immobilization with a plaster splint from the fingertips to the middle third of the forearm for 4-5 weeks.

4th zone - the zone from the wrist joint to the transition of the tendons into the muscles on the forearm - loss of the function of extension of the fingers and hand.

Treatment operational. When revising the wound to mobilize the extensor tendons near the wrist joint, it is necessary to cut the dorsal carpal ligament and the fibrous canals of the tendons that are damaged. Each tendon is sutured separately. The dorsal carpal ligament is reconstructed with lengthening. Fibrous channels are not restored. Immobilization is performed with a plaster splint for 4 weeks.

Diagnosis, clinical picture and treatment of fresh closed injuries of the extensor tendons of the fingers. Subcutaneous (closed) damage to the extensor tendons of the fingers is observed in typical locations - the long extensor of the first finger at the level of the third fibrous canal of the wrist; triphalangeal fingers - at the level of the distal and proximal interphalangeal joints.

With a fresh subcutaneous rupture of the tendon of the long extensor of the first finger at the level of the wrist joint, the function of extension of the distal phalanx is lost, extension in the metacarpophalangeal and metacarpal joints is limited. The function of stabilizing these joints is lost: the finger sag and loses its grip function.

Treatment operational. The most effective method is the transposition of the tendon of the extensor muscle of the second finger onto the extensor muscle of the first finger.

Fresh subcutaneous ruptures of the extensor tendons of the II-V fingers at the level of the distal phalanx with separation of a bone fragment and at the level of the distal interphalangeal joint are accompanied by loss of the function of extension of the nail phalanx. Due to the traction of the deep flexor tendon, the nail phalanx is in a forced flexion position.

Treatment of fresh subcutaneous ruptures of the extensor tendons of the II-V fingers is conservative. For closed tendon fusion, the distal phalanx is fixed in extension or hyperextension using various splints for 5 weeks. or fixation is performed with a Kirschner wire through the distal interphalangeal joint.

For fresh subcutaneous avulsions of the extensor tendons with a bone fragment with significant diastasis, surgical treatment is indicated.

A fresh subcutaneous rupture of the central part of the extensor apparatus at the level of the proximal interphalangeal joint is accompanied by limited extension of the middle phalanx and moderate swelling. With correct diagnosis in fresh cases, the finger is fixed in the position of extension of the middle phalanx and moderate flexion of the distal one. In this position of the finger, the lumbrical and interosseous muscles are most relaxed, and the lateral bundles are shifted towards the central bundle of the extensor apparatus. Immobilization continues for 5 weeks. (Fig. 6).

Rice. 6.

Old damage to the extensor tendons of the fingers. A wide variety of secondary deformities of the hand in chronic injuries of the extensor tendons is due to a violation of the complex biomechanics of the flexor-extensor apparatus of the fingers.

Damage in the 1st zone manifests itself in two types of finger deformation.

1. If the extensor tendon is completely damaged at the level of the distal interphalangeal joint, the function of extension of the distal phalanx is lost. Under the influence of tension in the deep flexor tendon, a persistent flexion contracture of the distal phalanx is formed. This deformity is called “hammer finger.” A similar deformity occurs when the extensor tendon is torn off with a fragment of the distal phalanx.

2. If the extensor tendon is damaged at the level of the middle phalanx proximal to the distal interphalangeal joint, the lateral bundles, having lost connection with the middle phalanx, diverge and shift in the palmar direction. In this case, active extension of the distal phalanx is lost and it takes a flexed position. Due to the violation of the fixation point of the lateral bundles, over time, the function of the central bundle, which extends the middle phalanx, begins to prevail. The latter occupies a hyperextension position. This deformity is called the “swan neck.”

Treatment of chronic damage to the extensor tendons in the 1st zone is surgical. The most important condition is the complete restoration of passive movements in the joint.

The most common operations are the formation of a scar duplication with or without dissection, and fixation of the distal interphalangeal joint with a wire. After removal of the needle after 5 weeks. after the operation a course is carried out rehabilitation treatment. In case of old injuries and persistent flexion contracture, arthrodesis of the distal interphalangeal joint in a functionally advantageous position is possible.

Old damage to the tendon-aponeurotic sprain in the 2nd zone at the level of the proximal interphalangeal joint is accompanied by two main types of deformity.

1. If the central bundle of the extensor tendon is damaged, the function of extension of the middle phalanx is lost. The lateral bundles, under the tension of the lumbrical muscles, shift in the proximal and palmar directions, promoting flexion of the middle phalanx and extension of the distal phalanx of the finger. The head of the proximal phalanx moves into the gap formed in the extensor aponeurosis, like a button passing into a loop.

A typical flexion-hyperextension deformity occurs, which has received several names: loop rupture, button loop phenomenon, triple contracture, double Weinstein contracture.

2. With chronic damage to all three bundles of the extensor tendon apparatus, a flexion position of the middle phalanx occurs. Hyperextension of the distal phalanx does not occur due to damage to the lateral bundles.

Treatment of chronic damage to the extensor tendon apparatus at the level of the proximal interphalangeal joint is surgical. In the preoperative period, a course of restorative treatment is carried out to eliminate contractures and restore the range of passive movements.

Weinstein's operation: after mobilization of the lateral bundles of the tendon-aponeurotic stretch, they are brought together and sutured “side to side” over the proximal interphalangeal joint. In this case, excessive tension of the lateral bundles occurs, which can lead to limited flexion of the finger (Fig. 7).

Rice. 7.

For chronic injuries of the extensor tendons with impaired finger function, surgical treatment is indicated. The choice of surgical treatment method depends on the condition of the skin, the presence of scars, deformities and contractures. One of the common methods is the formation of a scar duplication.

IN postoperative period immobilization lasts 4-5 weeks, after which a course of restorative treatment is carried out - ozokerite applications, lidase electrophoresis, massage, exercise therapy on the fingers and hand.

Traumatology and orthopedics. N. V. Kornilov

Sometimes such thickening is hereditary or occurs for no apparent reason, but often accompanies various diseases, including congenital cyanotic heart defects, infective endocarditis, lung diseases (lung cancer, lung metastases, bronchiectasis, lung abscess, cystic fibrosis and pleural mesothelioma), and some gastrointestinal diseases (Crohn's disease, ulcerative colitis and cirrhosis of the liver).

Reasons for the development of symptoms drumsticks unclear; perhaps it is due to the dilation of the vessels of the distal phalanges of the fingers under the influence humoral factors. In patients with lung cancer, pulmonary metastases, pleural mesothelioma, bronchiectasis, and liver cirrhosis, the drumstick symptom may be combined with hypertrophic osteoarthropathy. In this condition, periosteal bone formation occurs in the area of ​​the diaphysis of long tubular bones, arthralgia and symmetrical arthritis-like changes occur in the shoulder, knee, ankle, wrist and elbow joints. Diagnosis by radiography and bone scintigraphy.

The symptom of drumsticks is characteristic of all chronic lung infections.

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Phalanges of fingers

The phalanges of the human fingers have three parts: proximal, main (middle) and terminal (distal). On the distal part of the nail phalanx there is a clearly visible nail tuberosity. All fingers are formed by three phalanges, called the main, middle and nail. The only exception is thumbs- they consist of two phalanges. The thickest phalanges of the fingers form the thumbs, and the longest ones form the middle fingers.

Structure

The phalanges of the fingers belong to the short tubular bones and have the appearance of a small elongated bone, in the shape of a semi-cylinder, with the convex part facing the back of the hand. At the ends of the phalanges there are articular surfaces that take part in the formation of interphalangeal joints. These joints have a block-like shape. They can perform extensions and flexions. The joints are well strengthened by collateral ligaments.

Appearance of the phalanges of the fingers and diagnosis of diseases

In some chronic diseases of the internal organs, the phalanges of the fingers are modified and take on the appearance of “drumsticks” (spherical thickening of the terminal phalanges), and the nails begin to resemble “watch glasses”. Such modifications are observed in chronic lung diseases, cystic fibrosis, heart defects, infective endocarditis, myeloid leukemia, lymphoma, esophagitis, Crohn's disease, liver cirrhosis, diffuse goiter.

Fracture of the phalanx of the finger

Fractures of the phalanges of the fingers most often occur as a result of a direct blow. A fracture of the nail plate of the phalanges is usually always comminuted.

Clinical picture: the phalanx of the fingers hurts, swells, the function of the injured finger becomes limited. If the fracture is displaced, then the deformation of the phalanx becomes clearly visible. In case of fractures of the phalanges of the fingers without displacement, sprain or displacement is sometimes mistakenly diagnosed. Therefore, if the phalanx of the finger hurts and the victim associates this pain with injury, then an X-ray examination (fluoroscopy or radiography in two projections) is required, which allows making the correct diagnosis.

Treatment of a fracture of the phalanx of the fingers without displacement is conservative. An aluminum splint or plaster cast is applied for three weeks. After this, physiotherapeutic treatment, massage and exercises are prescribed physical therapy. Full mobility of the damaged finger is usually restored within a month.

In case of a displaced fracture of the phalanges of the fingers, comparison of bone fragments (reposition) is performed under local anesthesia. Then a metal splint or plaster cast is applied for a month.

If the nail phalanx is fractured, it is immobilized with a circular plaster cast or adhesive plaster.

The phalanges of the fingers hurt: causes

Even the smallest joints in the human body - the interphalangeal joints - can be affected by diseases that impair their mobility and are accompanied by excruciating pain. Such diseases include arthritis (rheumatoid, gout, psoriatic) and deforming osteoarthritis. If these diseases are not treated, then over time they lead to the development of severe deformation of the damaged joints, complete disruption of their motor function and atrophy of the muscles of the fingers and hands. Despite the fact that the clinical picture of these diseases is similar, their treatment is different. Therefore, if the phalanges of your fingers hurt, you should not self-medicate. Only a doctor, after conducting the necessary examination, can make the correct diagnosis and accordingly prescribe the necessary therapy.

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I only had the very tip of the bone removed, about 4 mm. and now the nail phalanx is 4 mm shorter, this is of course nothing, but it still catches the eye, and even the nail cannot really grow. With the help of what modern biotechnologies can this be cured? please give me the link.

I have thinned (decreased in diameter) forefinger hands in front of the nail plate. One gets the impression that there is just bone left in this place. The finger began to look like an irregularly shaped hourglass. The finger jerks periodically. The skin in this area is smooth and soft.

Possible causes are listed in the article, and the exact cause can only be determined after an examination.

The article lists those conditions that may be characterized by enlarged phalanges, and to find out for sure, you need face-to-face consultation from a specialist (for starters, an orthopedist or surgeon).

Hello. I'm afraid not.

If the diagnosis could be made in one sentence on the Internet, it would be very convenient, but unfortunately, this is not possible. You need to see a doctor in person and undergo an examination to get an answer to your question.

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How to treat arthrosis of the fingers using traditional and folk medicine

Typically, joint diseases occur in most cases in people of mature age.

But today, due to hormonal changes in the body, you can find many young girls suffering from arthrosis of the fingers, an inflammatory process that is localized on the joints of the hands.

Such manifestations cause discomfort to the fair sex not only due to the cosmetic effect, but also due to the loss of functions. Treatment should begin immediately, even at the stage of initial symptoms.

Concept and characteristics of the disease

The disease arthrosis – inflammation of a joint or joints – has not yet been fully studied.

Scientists cannot identify the exact causes of this disease, although they provide several hypotheses. The main hypothesis is that the cause of the disease is a hereditary factor.

That is, a person has a gene from birth that can lead to an inflammatory process as soon as there are grounds for this - the reasons for the disease.

Osteoarthritis of the fingers is no exception. Everything in this form inflammatory processes joints occur on the phalanges of the fingers.

In rare cases, the joints of the hands are affected - in this case, the disease polyarthrosis is diagnosed. The presented disease is dangerous for humans due to its irreversible manifestations. So, in advanced cases, deformation of the joint itself and the bone to which it is adjacent is diagnosed.

Such features of the disease can no longer be eliminated, and to improve the standard of living, experts suggest performing surgery.

A sick person has a characteristic thickening in the joints between the phalanges.

Causes and risk factors of the disease

The disease has following reasons for occurrence:

• old age of the patient - due to the characteristic depletion and thinning of the articular cartilage;
• During the period of hormonal imbalance (menopause in women and other diseases), metabolic disorders occur cartilage tissue;
• weakened immunity affects the exacerbation of existing arthrosis, and also provokes its initial occurrence;
• injuries and bruises of fingers;
• genetic characteristics that caused deformation and other defects in the development of joints;
• excessive physical labor, where the basis was work with the hands;
• excessive hypothermia;
• the presence of any disease, both articular and distinctive, for example, rheumatoid arthritis, gout, diabetes and others;
• metabolic disorders of the whole body;
• transferred infectious diseases– chlamydia and others.

Stages of the disease and characteristic signs

Symptoms of arthrosis of the fingers differ significantly depending on the stage of development of the disease.

So, there are three stages, each of which manifests itself in its own way:

1. The first stage is characterized by initial symptoms: pain in the joints occurs every time under heavy loads; there is a characteristic crunch in the fingers; swelling of the joints appears; diagnose joint compactions between the phalanges of the fingers; constant pressure periarticular muscle tissue, which is manifested by difficulties in self-care.
2. In the second stage, the person is bothered constant pain in the joints, as inflammation of the joints occurs. It is difficult for a person not only to serve himself, but also to simply move his fingers. Inflammation of the joints is always accompanied

In the photo there is stage 3 arthrosis of the fingers

an increase in local temperature (when palpated, you can notice an increase in temperature skin in the joints).

The third stage is the beginning of an irreversible process. A person suffers from constant pain in his fingers, and there is deformation of the phalanges. Bone deformation also leads to a lack of mobility in the fingers or all hands. Treatment of the third stage is extremely difficult and does not return a person to their previous life.

A person should contact a specialist at the first manifestations of the disease. At the first stage, treatment of arthrosis of the fingers can completely restore cartilage tissue and return the patient to his previous standard of living.

Rhizarthrosis of the thumb

Arthrosis of the thumb has a second name - rhizarthrosis. It appears quite rarely - in approximately 5% of all cases diagnosed with joint diseases.

In this case, the metacarpal joint is affected at the junction with the wrist bone. At the site of the lesion, deformation of the joint is observed with its protrusion outward.

Diagnostics in a medical institution

Pathology is diagnosed by visual examination by a doctor and subsequent X-ray examination.

In the picture you can see characteristic damage to the joints, as well as determine the stage of development of the disease presented.

Treatment methods

Treatment of the disease involves restoring the previous mobility of the joints by restoring cartilage tissue by any suitable method.

Traditional medicine and effective folk methods are used here.

Traditional medicine

Treatment methods using traditional medicine directly depend on the stage of manifestation of the disease.

1. Drug therapy - first of all, the specialist prescribes non-steroidal anti-inflammatory drugs to eliminate inflammation and pain. After some relief, the patient begins to take chondroprotectors - drugs for restoring cartilage tissue.
2. Physiotherapy – laser therapy, magnetic therapy, paraffin baths, ozokerite baths are used. The sessions are excellent for relieving pain.
3. Exercise therapy – the patient must do simple exercises to regain their previous mobility. Tapping your fingers on the table uses all your finger joints.
4. Massage - light stroking and rubbing - a gentle massage regimen performed by an experienced specialist.
5. Diet – throughout the entire treatment, the patient must adhere to a low-salt diet so that fluid does not remain in the body, and therefore does not provoke swelling and inflammatory processes.
6. Surgical intervention - the patient undergoes removal of growths in the joint parts, and in case of arthrosis of the thumb, the joint is immobilized by installing a fixator - arthrodesis.

Traditional medicine is used in a comprehensive manner in most cases. The patient must follow all the doctor’s instructions in order to quickly eliminate the pain syndrome and return to the previous level of life.

ethnoscience

Treatment of arthrosis of the fingers folk remedies used only to relieve pain, eliminate swelling and inflammation, since they do not stop the process of destruction of cartilage tissue that has begun and do not help restore the balance of microelements.

In particular, the following recipes are used:

1. Mix honey and salt in equal proportions. Mix the mixture thoroughly and apply it to sore joints. Cover your hands with plastic and put on wool mittens. Leave the compress on overnight.
2. It is recommended to make a compress for the night from crushed burdock leaves. They are pre-washed and passed through a meat grinder.

In addition to compresses for the treatment of arthrosis, you can use infusions and other formulations for oral administration. Extract the juice from fresh celery and take 2 teaspoons three times a day.

Be careful, complications are possible!

Pathology with untimely intervention is fraught with serious consequences.

Surgical intervention is the result of complications of the onset of the disease, since the surgical method is used in case of deformation of the joint and adjacent bone.

Therefore, at the first manifestations of aching fingers, you should contact specialists for help.

Prevention methods

As preventive measures, experts recommend eating right - eating more vegetables and fruits, and not overusing salt.

Distribute physical activity It is correct that the fingers do not take all the weight on themselves. If you have relatives in your family with similar problems, take preventative measures diligently.

Hand health directly depends on a person’s attitude towards himself. In a busy world, you often don’t find time to visit a doctor in the initial stages of a serious illness.

This kind of negligence can lead to significant problems that will take a long time to resolve.

Phalanges of fingers

The phalanges of the fingers of the human upper limbs consist of three parts - proximal, middle (main) and distal (final). The distal part of the phalanx has a clearly visible nail tuberosity. All fingers of the human hand are formed by three phalanges - nail, middle and main. If we talk about the thumb, it consists of two phalanges. The longest phalanges form the middle fingers, and the thickest ones form the thumbs.

The structure of the phalanges of the fingers

According to anatomists, the phalanges of the fingers of the upper extremities are short tubular bones, which have the shape of a small elongated bone, in the form of a cylinder, with its convex part facing the back of the palms. Almost each end of the phalanges has articular surfaces that take part in the formation of interphalangeal joints. These joints have a block-like shape. They perform two functions - flexion and extension of the fingers. The interphalangeal joints are strengthened by collateral ligaments.

What diseases cause changes in the appearance of the phalanges of the fingers?

Very often, with chronic ailments of the internal organs, the phalanges of the fingers of the upper extremities are modified. They, as a rule, take on the appearance of “drum sticks” (a spherical thickening is observed on the terminal phalanges). As for the nails, they resemble “hour hands”. Similar modifications of the phalanges are observed in the following diseases:

• heart defects;
• cystic fibrosis;
• lung diseases;
• infective endocarditis;
• diffuse goiter;
• Crohn's disease;
• lymphoma;
• cirrhosis of the liver;
• esophagitis;
• myeloid leukemia.

The phalanges of the fingers hurt: the main causes

The interphalangeal joints (the smallest joints in the human body) can be affected by diseases that impair their mobility. These diseases are in most cases accompanied by excruciating pain. The main causes of impaired mobility of the interphalangeal joints are:

• deforming osteoarthritis;
• gouty arthritis;
• rheumatoid arthritis;
• psoriatic arthritis.

If these ailments are not treated, then after some time they will lead to severe deformation of the diseased joints, complete disruption of their motor function, as well as atrophy of the hands and muscles of the fingers. The clinical picture of the above ailments is very similar, but their treatment is different. Therefore, medical specialists advise people who have pain in the phalanges of their fingers not to self-medicate, but to contact experienced doctors.

Fracture of the phalanx of the finger

Judging by the reviews of medical specialists, fractures of the phalanges of the fingers, as a rule, occur as a result of a direct blow. If we talk about a fracture of the nail plate of the phalanx, then it is almost always fragmented. Such fractures are accompanied severe pain in the area of ​​damage to the phalanx, swelling and limitation of the function of the broken finger.

Treatment of fractures of the phalanges of the fingers of the upper extremities without displacement is conservative. In this case, traumatologists apply a plaster cast or an aluminum splint for three weeks, after which they prescribe therapeutic massage, physical education and physiotherapeutic procedures. In case of a displaced fracture, reposition (comparison of bone fragments) is performed under local anesthesia. A plaster cast or metal splint is applied for a month.

What diseases are accompanied by bumps on the phalanges of the fingers?

Bumps on the phalanges of the fingers are manifestations of many diseases, the main ones of which are:

Bumps that appear on the fingers of the upper extremities are accompanied by unbearable pain, which intensifies at night. In addition, there is a characteristic compaction, leading to immobility of the joints, as well as limitation of their flexibility.

As for the treatment of these bumps, it consists of drug therapy, therapeutic and preventive gymnastics, massage, physiotherapeutic procedures and applications.

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The information presented on our website should not be used for self-diagnosis and treatment and cannot serve as a substitute for consultation with a doctor. We warn you about the presence of contraindications. Specialist consultation is required.

Thickening of the terminal phalanges of the fingers or toes

Thickening of the terminal phalanges of the fingers or toes are changes in the area under and around the nails. Thickening of the terminal phalanges of the fingers does not in itself pose any health hazard. However, it is often a symptom of lung disease; however, many other diseases can be the cause. Thickening of the terminal phalanges of the fingers, not associated with any diseases, is inherited in some families.

Symptoms

Softening nails. The nails may seem to “float” - that is, not be firmly attached;

The angle between the nails and the cuticle increases;

The last part of the finger may appear large or protruding. It can also be warm and red;

Curve nails downward, similar to the shape of the round part of an inverted spoon.

Thickenings can develop quickly, often within a few weeks. They can also be easily eliminated once the cause is clear.

Causes of thickening of the terminal phalanges of the fingers or toes

Lung cancer is the most common cause of this disease. Thickenings often develop due to diseases of the heart and lungs, which reduce the amount of oxygen in the blood, such as:

Heart defects that are present at birth (congenital);

Chronic pulmonary infections in humans: bronchiectasis, cystic fibrosis (a systemic hereditary disease caused by a mutation in the gene for the transmembrane regulator of cystic fibrosis and characterized by damage to the exocrine glands, severe dysfunction of the respiratory and gastrointestinal tract; the most common autosomal recessive potentially lethal hereditary disease in white people race), lung abscess;

Infection of the lining of the heart chambers and heart valves (infectious endocarditis), which may be caused by bacteria, fungi, or other infectious agents;

Lung diseases in which the deep tissues of the lungs swell and then form a scar (interstitial lung disease).

Other causes of thickening of the phalanges of the fingers:

Celiac disease (or celiac enteropathy is a multifactorial disease, a digestive disorder caused by damage to the villi of the small intestine by certain food products containing proteins - gluten and related cereal proteins);

Liver cirrhosis and other liver diseases;

Graves' disease (diffuse toxic goiter, Graves' disease - a life-threatening disease of the thyroid gland);

Overactive thyroid gland;

Other types of cancer, including liver and gastrointestinal tract, Hodgkin's lymphoma.

Diagnosis and treatment of thickening of the terminal phalanges of the fingers or toes

The patient should contact his doctor if he notices thickening of the terminal phalanges of the fingers or toes.

Diagnosis is usually based on:

Examination of the lungs and chest.

The doctor's questions to the patient may include the following:

Does he have difficulty breathing;

Do the bulges affect the mobility of his fingers and toes;

When did this thickening first become noticeable;

Is the skin bluish in color at the site of thickening;

What other symptoms accompany this disease?

The following tests can be done:

Arterial blood gas analysis;

CT scan of the chest;

Pulmonary function test.

There is no specific treatment for such thickenings of the terminal phalanges, but treatment concomitant diseases almost always leads to the elimination of these thickenings.

Thickening of the terminal phalanges of the fingers like “drumsticks”

CLINICAL CASE

A 31-year-old man with a congenital heart defect has had thickened terminal phalanges of his fingers like “drum sticks” since childhood (Fig.). Upon closer examination, thickening of the distal phalanges is visible in the “drumstick” type. He has become accustomed to living with the limitations caused by his congenital heart defect, and his fingers do not bother him at all.

EPIDEMIOLOGY

Prevalence in the general population is unknown:

• 2% of adult patients seeking care in Wales.
• 38% of patients with Crohn's disease and 15% of patients with ulcerative colitis.
• 33% of patients with lung cancer and 11% with COPD.

DRAWING. Thickening of the phalanges like “drumsticks” in a 31-year-old man with congenital heart disease. Noteworthy is the thickening around the proximal edge of the nail.

ETIOLOGY AND PATHOPHYSIOLOGY

The etiology is poorly understood.

Megakaryocytes and platelet accumulations penetrate the histemic bloodstream; from platelets release platelet-derived growth factor, which can cause thickening of the nail bed.

DIAGNOSIS and CLINICAL SIGNS

• Usually painless.
• Changed angle of the nail (Fig.).
• Angle to profile (ABC) > 180°.
• Hyponychial angle (ABD) > 192°.
• Phalanx depth ratio (BE:GF) > I

TYPICAL LOCATION

• Bilateral, all fingers and sometimes toes are involved.
• Rarely unilateral or involving one or more fingers.

DIFFERENTIAL DIAGNOSIS

PRIMARY THICKENING OF THE END PHALANGES ACCORDING TO THE TYPE OF “DRUM STICKS”

• Pachydermoperiostosis.
• Familial thickening of the terminal phalanges of the “drumstick” type.
• Hypertrophic osteoarthropathy.

SECONDARY THICKENING OF THE TERMINAL PHALANGES ACCORDING TO THE TYPE OF “DRUMP STICKS”

Secondary thickening of the terminal phalanges in the form of “drumsticks” can be caused by many diseases, including the following:

• Gastrointestinal diseases: inflammatory bowel disease, liver cirrhosis and celiac disease.
• Lung diseases: malignant neoplasms, asbestosis, ischemic obstructive pulmonary diseases, cystic fibrosis.
• Heart disease: congenital heart defects, endocarditis, atrioventricular malformations or fistulas.

TREATMENT

DRAWING. Thickening of the phalanges like “drumsticks” close-up.

DRAWING. Thickening of the phalanges in the form of “drumsticks” in a 55-year-old man suffering from COPD. Changed angle in profile (ABC); the depth of the distal phalanx (BE) is greater than the interphalangeal depth (GF)

Drumstick symptom

The symptom of drumsticks (Hippocratic fingers or drum fingers) is a painless, flask-shaped thickening of the terminal phalanges of the fingers and toes that does not affect the bone tissue, which is observed in chronic diseases of the heart, liver or lungs. Changes in the thickness of the soft tissues are accompanied by an increase in the angle between the posterior nail fold and the nail plate to 180° or more, and the nail plates are deformed, resembling watch glasses.

General information

The first mention of fingers resembling drumsticks is found in Hippocrates in the description of empyema (an accumulation of pus in a body cavity or hollow organ), therefore such deformation of the fingers is often called Hippocratic fingers.

In the 19th century The German doctor Eugene Bamberger and the Frenchman Pierre Marie described hypertrophic osteoarthropathy (secondary damage to the long bones), in which “drumstick” fingers are often observed. These pathological conditions already by 1918, doctors considered it a sign of chronic infections.

Forms

In most cases, drumstick fingers are observed on the hands and feet simultaneously, but isolated changes also occur (only the fingers or only the toes are affected). Selective changes are characteristic of cyanotic forms of congenital heart defects, in which only the upper or lower half of the body is supplied with oxygenated blood.

Based on the nature of the pathological changes, fingers are classified as “drumsticks”:

• Resembling a parrot's beak. The deformity is associated primarily with the growth of the proximal part of the distal phalanx.
• Reminiscent of watch glasses. The deformity is associated with tissue growing at the base of the nail.
• True drumsticks. Tissue growth occurs along the entire circumference of the phalanx.

Reasons for development

The causes of the drumstick symptom may be:

• Lung diseases. The symptom appears with bronchogenic lung cancer, chronic suppurative lung diseases, bronchiectasis (irreversible local dilation of the bronchi), lung abscess, pleural empyema, cystic fibrosis and fibrous alveolitis.
• Cardiovascular diseases, which include infective endocarditis (heart valves and endothelium are affected by various pathogens) and congenital heart defects. The symptom accompanies the blue type of congenital heart defects, in which a bluish tint of the patient’s skin is observed (includes tetralogy of Fallot, transposition great vessels and pulmonary atresia).
• Gastrointestinal diseases. The symptom of drumsticks is observed in cirrhosis, ulcerative colitis, Crohn's disease, enteropathy (celiac disease).

Drumstick fingers can be a symptom of other types of diseases. This group includes:

• cystic fibrosis is an autosomal recessive disease that is caused by a CFTR mutation and manifests itself with severe respiratory impairment;
• Graves' disease (diffuse toxic goiter, Graves' disease), which is an autoimmune disease;
• trichocephalosis is a helminthiasis that develops when the gastrointestinal tract is affected by whipworms.

Fingers resembling drumsticks are considered the main manifestation of Marie-Bamberger syndrome (hypertrophic osteoarthropathy), which is a systemic lesion of long bones and in 90% of all cases is caused by bronchogenic cancer.

The cause of unilateral damage to the fingers may be:

• Pancoast tumor (occurs when cancer cells damage the first (apical) segment of the lung);
• lymphangitis (inflammation of the lymphatic vessels);
• application of an arteriovenous fistula to purify the blood using hemodialysis (used for renal failure).

There are other, little-studied and rare causes of the development of the symptom - taking losartan and other angiotensin II receptor blockers, etc.

Pathogenesis

The mechanisms of development of drumstick syndrome have not yet been fully established, but it is known that deformation of the fingers occurs as a result of impaired blood microcirculation and the local tissue hypoxia that develops as a result.

Chronic hypoxia causes dilation of blood vessels located in the distal phalanges of the fingers. There is also increased blood flow to these areas of the body. It is assumed that blood flow is increased due to the opening of arteriovenous anastomoses ( blood vessels, which connect arteries to veins), which occurs as a result of the action of an unidentified endogenous (internal) vasodilator.

The result of the broken humoral regulation becomes a growth lying between the bone and the nail plate connective tissue. Moreover, the more significant the hypoxemia and endogenous intoxication, the more severe the modifications of the terminal phalanges of the fingers and toes will be.

However, hypoxemia is not typical for chronic inflammatory bowel diseases. At the same time, changes in the fingers like “drum sticks” are not only observed in Crohn’s disease, but also often precede intestinal manifestations of the disease.

Symptoms

The symptom of drumsticks does not cause pain, so initially it develops almost unnoticed by the patient.

Signs of the symptom are:

• Thickening of the soft tissues at the terminal phalanges of the fingers, in which the normal angle between the digital fold and the base of the finger disappears (Lovibond angle). Usually the changes are more noticeable on the fingers.
• Disappearance of the gap that normally forms between the nails if the nails of the right and left hands are placed together (Shamroth’s symptom).
• Increasing curvature of the nail bed in all directions.
• Increased looseness of tissue at the base of the nail.
• Special elasticity of the nail plate during palpation (balling the nail).

When the tissue at the base of the nail grows, the nails become like watch glasses.

Front view Side view

Signs of the underlying disease are also observed.

In many cases (bronchiectasis, cystic fibrosis, lung abscess, chronic empyema), the symptom of drumsticks is accompanied by hypertrophic osteoarthropathy, which is characterized by:

• aching pain in the bones (in some cases severe) and painful sensations upon palpation;
• the presence of shiny and often thickened skin that is warm to the touch in the pretibial area;
• symmetrical arthritis-like changes in the wrist, elbow, ankle and knee joints (one or more joints may be affected);
• coarsening of the subcutaneous tissues in the area of ​​the distal arms, legs, and sometimes the face;
• neurovascular disorders in the hands and feet (paresthesia, chronic erythema, increased sweating).

The time for symptom development depends on the type of disease that provoked the symptom. Thus, a lung abscess leads to the disappearance of the Lovibond angle and the balloting of the nail 10 days after aspiration (foreign substances entering the lungs).

Diagnostics

If the symptom of drumsticks occurs in isolation from Marie–Bamberger syndrome, the diagnosis is made based on the following criteria:

• There is no Lovibond angle, which can be easily established by applying a regular pencil to the nail (along the finger). The absence of a gap between the nail and the pencil indicates the presence of the drumstick symptom. The disappearance of the Lovibond angle can also be determined thanks to the Shamroth symptom.
• Elasticity of the nail upon palpation. To check for a runaway nail, press on the skin just above the nail and then release it. If the nail sinks into the soft cloth, and after the skin is released, it springs back, suggesting the presence of a drumstick symptom (a similar effect is observed in older people and in the absence this symptom).
• Increased ratio between the thickness of the distal phalanx at the cuticle and the thickness of the interphalangeal joint. Normally, this ratio averages 0.895. In the presence of the drumstick symptom, this ratio is equal to or greater than 1.0. This ratio is considered a highly specific indicator of this symptom (in 85% of children with cystic fibrosis, this ratio exceeds 1.0, and in children suffering from chronic bronchial asthma, this ratio is exceeded in only 5% of cases).

If a combination of the drumstick symptom with hypertrophic osteoarthropathy is suspected, bone radiography or scintigraphy is performed.

Diagnosis also includes studies to identify the cause of the symptom. For this:

• study anamnesis;
• do an ultrasound of the lungs, liver and heart;
• a chest x-ray is performed;
• CT and ECG are prescribed;
• examine the functions of external respiration;
• determine the gas composition of the blood;
• do a general blood and urine test.

Treatment

Treatment for drumstick-type finger deformities involves treating the underlying disease. The patient may be prescribed antibiotic therapy, anti-inflammatory therapy, diet, immunomodulatory drugs, etc.

Forecast

The prognosis depends on the cause of the symptom - if the cause is eliminated (cure or stable remission), symptoms may regress and the fingers will return to normal.

Among all bone fractures, the data is 5%.

Fractures of the second finger are more common, with the fifth finger in second place.

In almost 20% of cases, multiple fractures of the phalanges of various fingers are observed.

Damage to the main phalanges most often occurs, then to the nail and rarely to the middle phalanges.

Four of the five fingers of the hand consist of three phalanges - the proximal (upper) phalanx, the middle and the distal (lower).

The thumb is formed by a proximal and distal phalanx.

Distal phalanges the shortest, proximal - the longest.

Each phalanx has a body, as well as a proximal and distal end. For articulation with neighboring bones, the phalanges have articular surfaces (cartilage).

Causes

Fractures occur at the level of the diaphysis, metaphysis and epiphysis.

They are available without offset or with offset, open and closed.

Observations show that almost half of phalangeal fractures are intra-articular.

They condition functional disorders brushes Therefore, phalangeal fractures should be considered as a severe injury in a functional sense, the treatment of which must be approached with the utmost seriousness.

The mechanism of fractures is predominantly direct. They occur more often in adults. The blows fall on the back surface of the fingers.

Symptoms

Throbbing pain, deformation of the phalanges, and in case of non-displaced fractures - deformation due to swelling, which spreads to the entire finger and even the back of the hand.

Displacements of fragments are often angular, with lateral deviation from the axis of the finger.

Typical for a phalangeal fracture is the inability to fully extend the finger.

If you place both hands with your palms on the table, then only the broken finger does not adhere to the plane of the table. With displacements along the length, shortening of the finger and phalanx is noted.

For fractures of the nail phalanges

Subungual hematomas occur. Active and passive movements of the fingers are significantly limited due to exacerbation of pain, which radiates to the tip of the finger and is often pulsating.

The severity of the pain corresponds to the site of the phalanx fracture.

Not only the function of the fingers is impaired, but also the grasping function of the hand.

When the dorsal edge of the nail phalanx is torn off

When the dorsal edge of the nail phalanx is torn off (Bush fracture) with the extensor tendon, the nail phalanx is bent and the victim cannot actively straighten it.

Intra-articular fractures cause deformation of the interphalangeal joints with axial deviations of the phalanges.

Axial pressure on the finger aggravates the pain at the site of the phalanx fracture. In fractures with displaced fragments, pathological mobility is always a positive symptom.

Diagnostics

X-ray examination clarifies the level and nature of the fracture.

First aid

Any fracture requires temporary fixation before medical intervention, so as not to aggravate the injury.

If the phalanges of the hand are fractured, two or three ordinary sticks can be used for fixation.

They need to be placed around the finger and wrapped with a bandage or any other cloth.

As a last resort, you can bandage the damaged finger to a healthy one. If a painkiller tablet is available, give it to the victim to reduce pain.

A ring on an injured finger provokes an increase in swelling and tissue necrosis, so it must be removed in the first seconds after the injury.

In the case of an open fracture, it is prohibited to set the bones yourself. If disinfectants are available, you need to treat the wound and carefully apply a splint.

Treatment

No offset

Fractures without displacement are subject to conservative treatment with plaster immobilization.

Displaced fractures with a transverse or close to it plane are subject to closed one-step comparison of fragments (after anesthesia) with plaster immobilization for a period of 2-3 weeks.

Working capacity is restored after 1.5-2 months.

With an oblique fracture plane

Treatment with skeletal traction or special compression-distraction devices for fingers.

For intra-articular fractures

Intra-articular fractures, in which it is not only possible to eliminate the displacement, but also to restore the congruence of the articular surfaces, are subject to surgical treatment, which is carried out with open reduction with osteosynthesis of fragments, and early rehabilitation.

Must be remembered that treatment of all phalangeal fractures should be carried out in the physiological position of the fingers (half-bent at the joints).

Rehabilitation

Rehabilitation for finger fractures is one of the components complex treatment, and it has an important place in restoring finger function.

On the second day after the injury, the patient begins to move the healthy fingers of the injured hand. The exercise can be performed synchronously with a healthy hand.

The damaged finger, which is accustomed to being in a motionless state, will not be able to freely bend and straighten immediately after the immobilization is removed. To develop it, the doctor prescribes physiotherapeutic treatment, electrophoresis, UHF, magnetic therapy, and physical therapy.

Lower limb

Bones lower limb are divided into four main groups: (1) foot, (2) lower leg, (3) thigh (femur), (4) hip joint. This chapter presents detailed review X-ray anatomy and styling for three of them: feet, lower legs, middle And distal sections femur, including ankle And knee joints.

FOOT

The bones of the foot are generally similar to the bones of the hand and wrist studied in Chapter 4. The 26 bones of one foot are divided into four groups

Phalanges (toes) 14

Metatarsal bones (instep) 5

Tarsal bones 7

Phalanges of the toes

The distal part of the foot is represented by phalanges, forming fingers. The five toes of each foot are numbered first through fifth, respectively, if counted from the medial edge or from the big toe. Note that the first, or thumb, finger has only two phalanges, proximal and distal, as well as the thumb. The second to fifth toes of each foot also have medial phalanx. Thus, two phalanges of the thumb and three in each finger from the second to the fifth make up a total 14 phalangeal bones.

The similarity with the hand in this case is obvious, since each hand also has 14 phalanges. However, the phalanges of the foot are shorter than the phalanges of the hand, and their range of motion is significantly less.

When describing any bone or joint, it is necessary to indicate which toe and which foot it belongs to. For example, the description - the distal phalanx of the first toe of the right foot - gives the exact location of the bone.

The distal phalanges of fingers 2-5 are so small that it is quite difficult to see them as separate bones on an x-ray.

Metatarsus bones

Five metatarsal bones form the instep of the foot. They are numbered in the same way as the fingers, from one to five, counting from the medial edge to the lateral.

In each metatarsal bone three parts are distinguished. The small rounded distal part is called head. The elongated thin middle part is called body. The slightly expanded proximal end of each metatarsal bone is called basis.

Lateral division base of the fifth metatarsal has a protruding uneven tuberosity, which is the site of attachment of the tendon. The proximal fifth metatarsal and its tuberosity are usually clearly visible on radiographs, which is important because this area of ​​the foot is often injured.

(5-6-7) 1, 2, 3 Cuneiformia

The resemblance of the tarsus to that of the upper limb is not so obvious because the tarsus has seven bones, as opposed to the eight bones of the carpus. At the same time, the tarsal bones are larger than the carpal bones and are less mobile, since they form the basis for supporting the body in vertical position.

The seven bones of the tarsus are sometimes classified as bones of the ankle joint, although only one bone, the talus, directly belongs to this joint. Each of the tarsal bones will be further considered separately, along with all the bones with which it has articulations.

Heel bone (Calcaneus)

The heel bone is the largest and strongest bone in the foot. Its posteroinferior section is formed by a well-defined process - tubercle of the calcaneus. Its uneven, rough surface is the site of attachment of muscle tendons. The lower expanded section of the tubercle passes into two small rounded processes: the larger one lateral and the smaller, less frequently mentioned, medial process.

On the lateral surface of the calcaneus there is fibular block, which can have different sizes and shapes and is visualized laterally in the axial projection image. On the medial surface, in its anterior section, there is a large protruding process - support of the talus.

Articulations. The calcaneus articulates with two bones: in the anterior part with the cuboid and in the upper part with the talus. Connection with talus forms an important subtalar joint. This articulation involves three articular surfaces that provide redistribution of body weight to maintain it in an upright position: this is an extensive posterior articular surface and two smaller ones - anterior and middle articular surfaces.

Note that the middle articular surface is top part the prominent buttress of the talus, which provides medial support for this important supporting joint.

The depression between the posterior and middle articular surfaces is called groove of the calcaneus(Fig. 6-6). In combination With similar to the groove of the talus, it forms an opening for the passage of the corresponding ligaments. This hole, located in the middle of the subtalar joint, is called sinus tarsus(rice. 6-7).

Talus

The talus is the second large bone of the tarsus, it is located between the lower part of the tibia and the heel bone. Together with the ankle and talocalcaneal joints, it participates in the redistribution of body weight.

Articulations. The talus articulates with four bones: top with tibia and tibia, from below with calcaneal and in front with scaphoid.

Arches of the feet

Longitudinal arch of the foot. The bones of the foot form longitudinal and transverse arches, providing powerful spring-type support for the weight of the entire body. The springy longitudinal arch is formed by medial and lateral components and is located mostly at the medial edge and center of the foot.

The transverse arch runs along the plantar surface of the distal tarsus and tarsometatarsal joints. The transverse arch is formed mainly by the sphenoid bones, especially the short second, in combination with the largest sphenoid and cuboid bones (Fig. 6-9).

ANKLE JOINT

Front view

Ankle joint formed by three bones: two long bones of the lower leg, tibial and fibular and one tarsal bone - the talus. The expanded distal part of the thin fibula extending onto the talus is called the external (lateral) ankle.

The distal portion of the larger and more powerful tibia has a widened articular surface for articulation with an equally wide superior articular surface of the talus. The medial elongated process of the tibia, extended along the medial edge of the talus, is called the internal (medial) ankle.

The inner parts of the tibia and fibula form a deep U-shaped cavity, or joint space, covering the block of the talus on three sides. However, it is impossible to examine all three parts of the gap in a direct (posterior) projection, since the distal parts of the tibia and fibula are covered by the talus. This is because the distal fibula is located somewhat posteriorly, as shown in the pictures. Posterior projection with an inward rotation of the foot by 15°, called projection of the joint space 1 and shown in Fig. 6-15, allows a full view of the open articular space above the talus.

Anterior tubercle- a small expanded process located laterally and anteriorly in the lower part of the tibia, articulates with the upper lateral part of the talus, while partially overlapping the fibula in front (Fig. 6-10 and 6-11).

Distal articular surface of the tibia forms the roof of the fork and is called the ceiling of the tibia. In some types of fractures, especially in children and adolescents, damage to the distal epiphysis and ceiling of the tibia occurs.

Side view

In Fig. Figures 6-11 show the ankle joint in a true lateral view, which shows that the distal fibula is located approximately 1 cm posterior to the tibia. This relative position becomes important in determining the true lateral position of the lower leg, ankle joint and foot. The main mistake when placing the ankle joint laterally is slight rotation of the joint, as a result of which the medial and lateral malleoli practically overlap each other. However, this will result in the ankle joint being depicted in an oblique projection, as shown in the figures. Thus, with true lateral projection lateral malleolus located approximately at 1 cm posterior from the medial malleolus. In addition, the lateral malleolus is also longer adjacent - medial approximately on 1 cm (this is better seen in the frontal projection, Fig. 6-10).

Axial (axial) view

An axial view of the inner edge of the distal fibula and tibia is shown in Fig. 6-12. The roof of the lower surface of the tibia (the roof of the tibia) is shown in this figure from the inside, in the end view of the ankle joint. The relationship is also visible lateral and medial malleolus fibula and tibia, respectively. Smaller, fibula located more posteriorly A line drawn through the center of both ankles is at an angle of approximately 15-20° to the frontal plane (parallel to the front surface of the body). Consequently, in order for the intermalleolar line to become parallel to the frontal plane, the shin and ankle

This joint should be rotated 15-20°. This relationship of the distal tibia and fibula is important when positioning the ankle joint or ankle slot in various projections, as described in the positioning sections of this chapter.

Ankle joint

The ankle joint belongs to the group block-type synovial joints, in which only flexion and extension movements are possible (dorsial flexion and plantar flexion). This is facilitated by strong collateral ligaments that pass from the medial and lateral malleolus to the calcaneus and talus. Significant lateral pressure can cause sprain of the ankle joint, accompanied by stretching or rupture of the lateral ligaments and rupture of the muscle tendons, which leads to expansion of the intra-articular space on the side of the injury.

1 Frank ED et al: Radiography of the ankle mortise, Radiol Technol 62-65: 354-359, 1991.

EXERCISES ON RADIOGRAMS

The following radiographs of the foot and ankle in the three most common projections provide an anatomical overview of the bones and joints. To conduct a review test, you are asked to name (or write down) all the parts marked in the pictures, having previously closed the answers given below.

Left foot, lateral view (Fig. 6-13)

A. Tibia.
B. Heel bone.

B. Tubercle of the calcaneus.
D. Cuboid bone.

D. Tuberosity of the fifth metatarsal bone.

E. Superimposed sphenoid bones. G. Scaphoid bone.

3. Subtalar joint. I. Talus.

Oblique projection of the right foot(rice. 6-14)

A. Interphalangeal joint of the first toe of the right foot.
B. Proximal phalanx of the first toe of the right foot.

B. Metatarsophalangeal joint of the first toe of the right foot.
D. Head of the first metatarsal bone.

D. Body of the first metatarsal bone. E. Base of the first metatarsal bone.

G. Second, or intermediate, sphenoid bone(partially covered by the first, or medial, sphenoid bone). 3. Scaphoid bone. I. Talus. K. Tubercle of the calcaneus. L. Third, or lateral, sphenoid bone. M. Cuboid bone.

N. Tuberosity of the base of the fifth metatarsal bone. O. The fifth metatarsophalangeal joint of the right foot. P. Proximal phalanx of the fifth toe of the right foot.

Projection of the joint space of the right ankle joint(Fig. 6-15)

A. Fibula.
B. Lateral malleolus.

B. Open joint space of the ankle joint.
G. Talus.

D. Medial malleolus.

E. The lower articular surface of the tibia (the articulating surface of the epiphysis).

Lateral projection of the ankle joint(rice. 6-16)

A. Fibula.
B. Heel bone.

B. Cuboid bone.

D. Tuberosity of the base of the fifth metatarsal bone. D. Scaphoid bone.

E. Talus. G. Sinus of the tarsus.

3. Anterior tubercle. I. Tibia.

TIBIAL AND FIBAL BONES

The next group of bones of the lower limb, which will be discussed in this chapter, includes two bones of the lower leg: tibia And fibular

Tibia

The tibia is one of the largest bones in the human skeleton and serves as the supporting bone of the lower leg. It can be easily felt through the skin in the anteromedial part of the leg. It has three parts: central body And two ends.

Proximal section. The expanded lateral sections of the upper, or proximal, end of the tibia form two powerful processes - medial And lateral condyle.

On the upper surface of the head of the tibia, between the two condyles, is located intercondylar eminence, in which two small tubercles are distinguished, medial And lateral intercondylar tubercles.

The upper articular surface of the condyles has two concave articular surfaces, often called tibial plateau, which form an articulation with the femur. On the lateral projection of the lower leg it can be seen that The tibial plateau has an inclination of 10° to 20° in relation to a line perpendicular to the long axis of the bone (Fig. 6-18) 1. This important anatomical feature must be taken into account when laying to obtain a straight posterior projection of the knee joint, the central ray should run parallel to the plateau and perpendicular to the cassette. In this case, the joint space will appear open in the image.

In the proximal part of the bone, on its anterior surface, immediately behind the condyles, there is a rough protrusion - tibial tuberosity. This tuberosity is the attachment site of the patellar ligament, which contains the tendons of the large muscle of the anterior surface of the thigh. Sometimes adolescents experience separation of the tibial tuberosity from the shaft of the bone, a condition known as Osgood-Schlatter disease(see clinical indications, p. 211).

The body of the tibia is the long middle part of the bone located between its two ends. Along the anterior surface of the body, between the tibial tuberosity and the medial malleolus, there is a pointed crest, or leading edge tibia, which can be easily felt under the skin.

Diet department. The distal part of the tibia is smaller than the proximal one, it ends in a short process of a pyramidal shape, medial malleolus, which can be easily palpated in the medial area of ​​the ankle joint.

On the lateral surface of the lower end of the tibia there is a flat, triangular shape fibular notch, to which the lower end of the fibula is adjacent.

Fibula

The fibula is smaller and located laterally to the back in relation to the larger tibia. The upper, or proximal, part of the bone forms an expanded head, which articulates with the outer surface of the posteroinferior part of the lateral condyle of the tibia. The upper end of the head is pointed, it is called top head of the fibula.

Body The fibula is the long thin part between its two ends. Expanded distal fibula

1 Manager Bj: Handbooks in radiology, ed. 2, Chicago, 1997, Year Book Medical Publishers, Inc.

FEMUR

The femur, or femur, is the longest and most powerful of all the tubular bones of the human skeleton. This is the only one long bone between the hip and knee joints. Proximal parts The femur will be described in Chapter 7 along with the hip joint and pelvic bones.

Middle and distal femur, anterior view(rice. 6-19)

As with all tubular bones, the body of the femur is an elongated and thinner part. On the front surface lower section The patella, or kneecap, lies on the femur. The patella, the largest sesamoid bone in the skeleton, is located anterior to the distal femur. Please note that in the frontal view with the leg fully extended, the lower edge of the patella is approximately 1.25 cm higher, or more proximal, actually knee joint. It is important to remember this when positioning the knee joint.

The small, smooth, triangular-shaped depression on the front surface of the lower part of the femur is called the patellar surface (Figure 6-19). This depression is also sometimes called the intercondylar groove. In the literature, the definition of trochlear groove is also found (meaning a block-shaped formation, reminiscent of a spool of thread, which consists of the medial and lateral condyles with a depression between them). It is necessary to know all three terms as they relate to this recess.

With the leg straightened, the patella is located slightly above the patella surface. Lying deep within the muscle tendon, the patella, when the knee is bent, moves downward, or distally, along the patellar surface. This is clearly visible in Fig. 6-21, p. 204, which shows the knee joint in a lateral view.

Middle and distal femur, posterior view (Fig. 6-20)

On the posterior surface of the distal femur are two rounded condyles, separated in the distal posterior portion by a deep intercondylar fossa, or notch, above which the popliteal surface is located (see p. 204).

The distal portions of the medial and lateral condyles contain smooth articular surfaces for articulation with the tibia. When the femur is in a vertical position, the medial condyle is located slightly lower, or distal, to the lateral one (Fig. 6-20). This explains why the CL must be angled 5-7° cranially when performing a lateral view of the knee, which projects the condyles onto each other and the femur parallel to the cassette. An explanation for this is given additionally in Fig. 6-19, which shows that in a vertical anatomical position, when the condyles of the distal femur are parallel to the lower plane of the knee joint, the body of the femur in an adult is deviated from the vertical by approximately 10°. The value of this angle ranges from 5° to 15°". In short people with a wide pelvis, this angle will be larger, and in tall patients with a narrow pelvis, it will be correspondingly smaller. Thus, the value of this angle in women, as a rule, is more than men.

Characteristic difference between the medial and lateral condyles is the presence of the adductor tubercle, a slightly protruding area to which the adductor tendon attaches. This tubercle is located in the posterior

Keats TE et al: Radiology, 87:904, 1966.

Patella

Patella(patella) - a flat, triangular-shaped bone, approximately 5 cm in diameter. The patella appears upside down because its pointed apex forms an inferior edge, and rounded base- upper. Outer side anterior surface convex and rough, and the inner one is oval in shape back surface, articulating with the femur, smooth. The patella protects the front part of the knee joint from injury, in addition, it plays the role of a lever that increases lift the quadriceps femoris muscle, the tendon of which is attached to the tuberosity of the tibia of the leg. The patella in its upper position with a fully straightened limb and a relaxed quadriceps muscle is a mobile and easily displaced formation. If the leg is bent at the knee joint and the quadriceps muscle is tense, the patella moves down and is fixed in this position. Thus, it can be seen that any displacement of the patella is associated only with the femur and not with the tibia.

KNEE-JOINT

The knee joint is a complex joint that includes, first of all, femorotibial the joint between the two condyles of the femur and their corresponding condyles of the tibia. Also involved in the formation of the knee joint femoral-patellofemoral nickname joint, because the patella articulates with the anterior surface of the distal femur.

Menisci (articular discs)

The medial and lateral menisci are flat intra-articular cartilage discs between the superior articular surface of the tibia and the femoral condyles (Fig. 6-27). The menisci are crescent-shaped, their thickened peripheral edge gently declines towards the thinned central part. The menisci are a kind of shock absorbers that protect the knee joint from shock and pressure. It is believed that the menisci, together with the synovial membrane, are involved in the production of synovial fluid, which plays the role of lubricating the articular surfaces of the femur and tibia, covered with elastic and smooth hyaline cartilage.

I L A V A O

LOWER LIMB

Straight posterior projection of the lower leg (Fig. 6-29)

A. Medial condyle of the tibia.
B. Body of the tibia.

B. Medial malleolus.
D. Lateral malleolus.

D. Body of the fibula. E. Neck of the fibula. G. Head of the fibula. 3. Apex (styloid process) of the fibular head

I. Lateral condyle of the tibia. K. Intercondylar eminence (tibial crest

Lateral projection of the lower leg (Fig. 6-30)

A. Intercondylar eminence (tibial crest
bones).

B. Tibial tuberosity.

B. Body of the tibia.
D. Body of the fibula.

D. Medial malleolus. E. Lateral malleolus.

Straight posterior view of the knee joint (Fig. 6-31)

A. Medial and lateral intercondylar tubercles; you
stupas of the intercondylar eminence (crest of the tibia
cervical bone).

B. Lateral epicondyle of the femur.

B. Lateral femoral condyle.

D. Lateral condyle of the tibia. D. Upper articular surface of the tibia.

E. Medial condyle of the tibia. G. Medial condyle of the femur.

3. Medial epicondyle of the femur.

I. Patella (visible through the femur).

Lateral view of the knee joint (Fig. 6-32)

A. Base of the patella.
B. Apex of the patella.

B. Tibial tuberosity.
D. Neck of the fibula.

D. Head of the fibula. E. Apex of the head (styloid process) of the fibula

bones. G. Medial and lateral condyles superimposed on each other

3. Patellar surface (intercondylar, or trochlear groove).

Lateral projection of the knee joint (with slight rotation) (Fig. 6-33)

I. Tubercle of the adductor muscle. K. Lateral condyle. L. Medial condyle.

Tangential view (patellofemoral joint) (Fig. 6-34)

A. Patella.

B. Patellofemoral joint.

B. Lateral condyle.

D. Patellar surface (intercondylar, or trochlear, groove). D. Medial condyle.

The only exception to the group of synovial joints is distal tibiofibular joint, related to fibrous compounds, in which the articulation between the articular surfaces of the tibia and fibula occurs with the help of connective tissue. It refers to syndesmoses and is continuous motionless, or inactive joint (amphiarthrosis). The most distal part of this joint is smoothed and covered by the common synovial membrane of the ankle joint.

SURFACES AND PROJECTIONS OF THE FOOT Surfaces. Determining the surface of the foot can sometimes cause some difficulties, since the foot rear called top part. The back surface usually refers to rear parts bodies. In this case we mean dorsum of the foot, which is the upper, or opposite to the sole, surface. The sole of the foot is rear, or plantar, surface.

Projections. Posterior projection of the foot is plantar projection. Less commonly used anterior projection may also be called rear projection. Radiologists should be familiar with each of these terms and have a good understanding of the specific projection they are performing.

LAYINGS

General issues

X-rays of the lower extremity are usually performed on an imaging table, as shown in Fig. 6-38. Patients with severe trauma are often examined directly on a stretcher or gurney.

DISTANCE

The X-ray source/receiver distance (XRD) for radiography of the lower extremity is usually 100 cm. If the image is taken on a cassette located on the table deck, it should be taken into account that the distance from the table deck to the cassette holder is usually 8-10 cm, and therefore the emitter should raise further. When taking x-rays on a gurney or stretcher, use the depth gauge, usually located on the depth diaphragm of the machine, to set the RIP = 100 cm.

Radiation protection

When radiography of the lower extremity, gonadal protection is desirable, since the gonads are in close proximity to the irradiation zone. The gonad area can be protected with any leaded vinyl cover 1 . And although the requirements for radiation protection of gonads apply only to patients reproductive age and only if the gonads are directly located in the area of ​​the direct beam, it is recommended to use it in all cases.

DIAPHRAGM

The rules for diaphragming are always the same - the boundaries of the diaphragm area should be visible on all four sides of the image, but the images of the organs being examined should not be cut off. The minimum size cassette should be used to obtain an image of the area of ​​interest. Note that when radiography of the lower limb, small cassettes are most often used.

Several projections can be performed on one cassette for radiography of the lower extremity, so careful attention should be paid to diaphragm setting.

When using digital X-ray imaging receivers (particularly computed radiography systems with memory phosphor plates), cover the unused area of ​​the cassette with a sheet of leaded vinyl. The phosphor is very sensitive to scattered radiation, which can cause severe fog on subsequent radiographs.

If the aperture boundaries are visible from all four sides, then this makes it easier to find the center of the image - at the intersection of the diagonals.

GENERAL PRINCIPLES OF LAYING

For the upper and lower limbs when laying, the same rule applies - the long axis of the limb being examined should

Rice. 6-38. Exemplary placement for the mediolateral projection of the lower limb:

Correct direction of the CL;

Correct aperture;

Correct use of radiation protection;

Diagonal placement of the lower limb allows you to get
X-ray image of both joints

not located along the long axis of the cassette. If you need to perform several projections, then When taking multiple images on one cassette, the orientation of the limb must be maintained.

The exception is the adult shin. It is usually laid diagonally across the cassette so that the knee and ankle joints enter, as shown in Fig. 6-38.

CORRECT CENTERING

Accurate centering and positioning of the body part being examined, as well as the correct direction of the CL, are very important when radiography of the upper and lower extremities. The photographs should show open joint spaces and there should be no geometric distortions of the shape of the bones, that is, the part of the body being removed should be parallel to the plane of the cassette, and the CL should be directed perpendicular to the limb being removed. Follow the directions on the styling pages.

EXPOSURE SETTINGS

Exposure parameters for radiography of the lower limb:

1. Low or medium kV (50-70).

2. Short exposure time.

3. Small focus.

Correctly exposed radiographs of the lower extremity should show both soft tissue contours and clear trabecular bone structure.

RADIOGRAPHY IN PEDIATRICS

Firstly, you should speak to the child in a language he understands. Parents often assist in restraining the child, especially if it is not a case of trauma. At the same time, care should be taken to ensure their radiation protection. Braces are useful in many cases because they help the child keep the limb still and in the desired position. Soft pillows for ease of laying and straps for fixation are common tools. Sand cushions should be used carefully as they are heavy. Body thickness measurement - important factor in determining optimal exposure parameters.

In general, reduced exposure parameters are used in pediatrics due to the small size and low density of the limbs being examined. Use short exposure times, increasing the current (mA), - this reduces the dynamic blur of the image.

RADIOGRAPHY IN GERIATRICS

Elderly patients should be positioned for imaging with caution, and radiography of the lower extremity is no exception. Pay attention to signs of a hip fracture (leg excessively twisted). Routine positioning should be adjusted to suit the patient’s ability to bend limbs and personal pathology. When positioning the limb, pillows and supports should be used to ensure patient comfort.

Exposure parameters should be selected taking into account possible osteoporosis or osteoarthritis. Using short exposure times, increasing the current (mA), this reduces the dynamic blur of the image due to voluntary and involuntary movements.

ARTHROGRAPHY

Arthrography is commonly used to visualize large synovial joints such as the knee. It is performed by introducing contrast agents into the joint cavity under sterile conditions. Arthrography reveals diseases and injuries of the menisci, ligaments and tendons (see Chapter 21).

RADIONUCLIDE DIAGNOSTICS

Radionuclide scanning is intended for the diagnosis of osteomyelitis, metastatic processes in the bones, impacted fractures, as well as inflammatory diseases of the subcutaneous tissue. The organ being examined is assessed within 24 hours from the start of the study. Radionuclide testing is more informative than radiography, since it allows you to assess not only the anatomical, but also the functional state of the organ.

Clinical indications

Radiologists should be familiar with the most common clinical indications for lower extremity radiography, which are (the attached list is not complete):

Bone cysts- benign tumor-like formations, which are a cavity filled with serous fluid. They most often develop in children and are located mainly in the knee joint.

Chondromalacia patella- often called runner's knee. The pathology is based on dystrophic changes(softening) of cartilage, leading to its wear; accompanied by pain and constant irritation of the affected area. Runners and cyclists are often affected.

Chondrosarcoma- malignant tumor bones. The predominant localization is the pelvis and long tubular bones. It is more common in men over 45 years of age.

Ewing's sarcoma- primary malignant bone tumor is usually observed in childhood, from 5 to 15 years. The tumor is usually localized in the diaphysis of long tubular bones. The clinical picture includes pain, increased body temperature at the onset of the disease, and leukocytosis.

Exostosis, or osteochondroma- a benign tumor-like bone lesion, the essence of which is the overproduction of bone substance (the knee joint area is often affected). The tumor grows in parallel with the growth of the bone, moving away from the adjacent joint.