Metacarpophalangeal joints and their pathologies. Thickening of the phalanges of the fingers Proximal middle and distal phalanges of the fingers

The human hand is made up of many small joints. Thanks to this, fingers can perform quite complex movements: write, draw, play musical instruments. The brush is involved in any household activity of a person. Therefore, various joint pathologies in this area greatly reduce the quality of life. Indeed, due to the restriction of mobility, it becomes difficult to perform the simplest actions.

And most often the joints are affected, as this is the most vulnerable and subjected to heavy loads. Due to the structural features, inflammation, metabolic disorders or injuries can occur here. One of the most important and mobile joints of the hand is the metacarpophalangeal joint. It connects the metacarpal bones to the main phalanges of the fingers and provides mobility to the hand. Due to their location and function, these joints are most often subject to various pathologies.

general characteristics

The metacarpophalangeal joints of the hand are spherical joints with a complex structure. They are formed by the surfaces of the heads of the metacarpal bones and the bases of the first phalanges. After the wrist joint, these are the largest and most mobile in the hand. It is they who have the main burden in any work of the hand. The metacarpophalangeal joint of the thumb is slightly different due to its special structure, location and functions. Here it has a saddle shape, so it is not as mobile. But it is he who is responsible for the grasping movements of the hand.

This articulation can be easily seen if the hand is clenched into a fist. At the same time, the metacarpophalangeal joints of the four fingers form semicircular bulges, spaced from each other by about 1 cm. The most noticeable tubercle is in the area of the middle finger. Due to this arrangement, these joints are highly vulnerable and are often subjected to trauma or various pathological processes. In this case, not only the work of the brush is disturbed, but also the general working capacity of a person.

The metacarpophalangeal joints are the most mobile in the hand, they can bend, unbend, move in the lateral plane and even rotate

Movements in the joint

This joint is the most mobile among all the joints of the hand. It has quite complex biomechanics. Fingers in this place can perform the following movements:

flexion-extension;
abduction-adduction;
rotation.

Moreover, the last movements are available only for 4 fingers. The big one has a special structure - only two phalanxes. Therefore, his metacarpophalangeal joint is blocky - he can perform a limited number of movements. It only bends, all other movements are blocked and impossible even in a passive form. This articulation of the thumb repeats the shape and function of all other interphalangeal joints.

The metacarpophalangeal joints of the remaining fingers are more mobile. This is due to their special structure. The base of the phalanx is slightly smaller than the metacarpal head. Their strong connection is provided by a fibrocartilaginous plate. On the one hand, it serves for tight contact of the bones and stabilization of the joint, which is especially noticeable when the finger is extended. But when he starts to move, this plate slides, providing a greater range of motion.

A feature of this joint, due to which the finger can move in different directions, is the elasticity of its capsule and synovial membrane. In addition, the joint capsule has deep pockets in front and behind. They provide gliding of the fibrocartilaginous plate, and it is in these places that the tendons of the muscles that control the work of the fingers are attached.

Greater mobility of these joints is possible due to the presence of two types of ligaments. One is attached to the fibrocartilaginous plate and the metacarpal head. It ensures the normal sliding of this plate. Other ligaments are collateral, located on the sides of the fingers. They provide their flexion and extension, and also slightly limit the mobility of the joint. For example, with a bent finger, its movement in the lateral plane is impossible, that is, its abduction and adduction. The work of this joint is also controlled by the palmar ligament and the interdigital transverse.

Unlike the big one, which is bent less than 90 degrees in the metacarpophalangeal joint, the remaining fingers have a large range of motion. The index finger has the least mobility, it can bend 90-100 degrees, no more. Further to the little finger, the amplitude of movements, especially passive ones, increases. And the middle one cannot bend more than 90 degrees even passively due to the tension of the interdigital ligament, which prevents it from approaching the palm.

The metacarpophalangeal joints are the only ones in the hand that can unbend, however, with a small amplitude - no more than 30 degrees. Although in some people the mobility of the fingers can reach such an extent that they unbend at a right angle. In addition, in this place it is possible to perform rotational movements, both passive and active. But each person's mobility is different.

It is in these places that pain most often occurs with age-related changes in tissues, after increased stress, or with other pathologies.

Features of pathologies

Due to such a complex structure of the metacarpophalangeal joints and a large range of motion, they are most often exposed to injuries and various pathologies. Pain in this place may be associated with damage to the joint capsule, the surface of the heads of the bones, the cartilaginous plate or ligaments. They make it difficult to move the hand and lead to serious problems when performing normal activities. Therefore, you should not ignore the first symptoms of pathologies, the sooner treatment is started, the faster the function of the hand will recover.

Such diseases are most common in people over 40 years of age, which is associated with age-related changes in tissues and the consequences of increased stress. Moreover, the most susceptible to damage to the joints of the woman's hand. Indeed, during menopause, hormonal changes take place in their body, which negatively affects the work of the whole organism. In addition, pathologies of the metacarpophalangeal joints can occur due to injuries, increased stress, hypothermia, or infectious diseases.

If you experience pain in the hand, you should definitely consult a doctor for examination and an accurate diagnosis. After all, the treatment of different diseases is different, and their symptoms can often be the same. It is worth visiting a doctor if there is pain when moving a finger or at rest, swelling, redness of the skin, limited movement of the hand.

After diagnostic procedures, one of the following pathologies is usually detected:

rheumatoid arthritis;
psoriatic arthritis;
infectious arthritis;
osteoarthritis;
gout;
stenosing ligamentitis;
soft tissue inflammation;
injury.

These joints are often affected by arthritis, causing pain and inflammation.

Arthritis

Most often, the fingers of the hand are affected by arthritis. This is an inflammatory disease that affects the joint cavity. Arthritis can occur as a complication after a common infectious disease, injury, or as a result of pathologies of the immune system. The joints of the fingers can be affected by rheumatoid arthritis, psoriatic or infectious. Common symptoms of these diseases are pain, swelling, hyperemia, and limited mobility.

But there are differences between different types of arthritis. The rheumatoid form of the disease is characterized by a chronic course and symmetry of the lesions of the fingers on both hands. In psoriatic arthritis, inflammation of just one finger can develop. But all his joints are affected. At the same time, it swells up and becomes like a sausage.

In infectious arthritis, inflammation is associated with the entry of pathogenic microorganisms into the joint cavity. Mainly one joint is affected. There is a jerking pain, often very strong, swelling, fever. Sometimes pus accumulates in the joint cavity.

arthrosis

Chronic degenerative joint disease is arthrosis. It usually develops in several places at once, but often affects the base of the fingers. This pathology is characterized by aching pains that occur after exertion, stiffness of the joint, its deformation. All this leads over time to the inability to perform elementary finger movements: fasten buttons, hold a spoon, write something.

Arthrosis affects cartilage tissue, leading to its destruction. Therefore, the metacarpophalangeal joint with this pathology can quickly lose mobility. After all, its peculiarity is that a large range of movements is provided by the sliding of the fibrocartilaginous plate. And when it is destroyed, the joint is blocked.

Sometimes there is rhizarthrosis, in which the first finger is isolated. The reasons for the destruction of cartilage tissue in this place are regular increased loads on it. Rhizarthrosis must be differentiated from gout or psoriatic arthritis, the symptoms of which are similar, but their treatment is very different.

The destruction of cartilage tissue in arthrosis leads to severe deformity of the joints.

Gout

This is a pathology of metabolic processes, as a result of which the accumulation of uric acid in the blood and the deposition of salts in the joints begins. Gout usually affects the metatarsophalangeal joints of the foot, but in women, it can also occur on the thumbs.

The disease develops paroxysmal. During an exacerbation, there is a sharp severe pain in the joint, it swells and turns red. It becomes impossible to touch it and move your finger. The attack usually lasts from a few days to a week. Gradually, gout can lead to deformity of the joints and their complete immobility.

Inflammation of the ligaments

If the annular ligament of the fingers is affected, they speak of the development of stenosing ligamentitis. The main symptoms of the pathology resemble arthrosis - pain also occurs during movement. A characteristic feature of the disease is clearly audible clicks during movement, and sometimes jamming of the finger in a bent position.

Similar to this pathology is tendinitis - inflammation of the collateral or palmar ligaments. But its feature is the jamming of the finger in an extended position, often the patient cannot bend it on his own.

The metacarpophalangeal joint is very vulnerable, especially at the thumb

Injuries

Injuries to the metacarpophalangeal joints are common. Athletes are especially susceptible to them, but you can injure your hand even when doing homework with careless movement. The most common injury in this place is a bruise, which is accompanied by severe pain and the development of a hematoma. It is painful to move your finger, but all symptoms most often disappear quickly even without treatment.

A more serious injury is a dislocation. The metacarpophalangeal joint can be injured when it is overextended, for example, during sports or when falling. In this case, severe pain occurs, the joint is deformed and swells. Quite often there is a dislocation of the thumb, as it is subjected to the greatest stress. And opposing it to the rest of the brush makes it vulnerable.

Treatment

When treating pathologies in this place, it should be remembered that the immobilization of the metacarpophalangeal joints can only be carried out in the flexion position. Indeed, due to the peculiarities of the work of the collateral ligaments, their prolonged fixation can lead to further stiffness of the finger. Therefore, if immobilization is necessary, for example, after an injury, you need to do it correctly. It is best to use a ready-made orthosis or a bandage applied by a doctor. But otherwise, diseases of these joints are treated in the same way as similar pathologies in other places.

Most often, patients turn to the doctor because of pain. To get rid of them, drugs of the NSAID group or analgesics are prescribed. It can be "Baralgin", "Trigan", "Ketanov", "Diclofenac". Moreover, they can be used both internally and externally in the form of ointments. With severe pain, injections are sometimes made directly into the joint cavity. In advanced cases, corticosteroids may be used.

With the destruction of cartilage tissue, the use of chondroprotectors is effective. At the initial stage, they are able to completely stop tissue degeneration. Sometimes joint damage and metabolic disorders in them are associated with circulatory pathologies. In this case, "Actovegin", "Vinpocetine" or "Cavinton" may be prescribed. These drugs improve blood circulation and nerve conduction, as well as accelerate the processes of tissue regeneration. If the inflammation is caused by an infection, antibiotics are necessarily used: Ofloxacin, Doxycycline, Cefazolin and others.

In the treatment of these pathologies, it is especially important to relieve pain, which greatly reduces the performance of the hand.

After the disappearance of pain and inflammation, auxiliary methods of treatment are prescribed to restore the mobility of the fingers. These can be physiotherapy, for example, magnetotherapy, mud applications, paraffin, acupuncture, electrophoresis. Therapeutic gymnastics for the fingers is also useful, since prolonged immobilization can lead to muscle atrophy. Special exercises prevent the development of stiffness, improve blood circulation and tissue nutrition.

The metacarpophalangeal joints are the most important for the normal functioning of the hand. But injuries and various pathologies that affect this joint can lead to a complete loss of its performance.

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

Structure

The phalanges of the fingers are short tubular bones and look like a small elongated bone, in the form of a semi-cylinder, with a convex part facing the back of the hand. At the ends of the phalanges are the articular surfaces that take part in the formation of interphalangeal joints. These joints are block-shaped. They can perform extensions and flexions. The joints are well reinforced with collateral ligaments.

The appearance of the phalanges of the fingers and the 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" (a 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. Fracture of the nail plate of the phalanges is usually always shrapnel.

Clinical picture: the phalanx of the fingers hurts, swells, the function of the damaged finger becomes limited. If the fracture is displaced, then the deformation of the phalanx becomes clearly visible. With fractures of the phalanges of the fingers without displacement, stretching or displacement is sometimes misdiagnosed. Therefore, if the phalanx of the finger hurts and the victim associates this pain with an injury, then an x-ray examination (fluoroscopy or radiography in two projections) should be required, which allows you to make 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 that, physiotherapy treatment, massage and physiotherapy exercises are prescribed. Full mobility of the injured finger is usually restored within a month.

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

In case of a fracture of the nail phalanx, it is immobilized with a circular plaster bandage or adhesive plaster.

Phalanges of 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, gouty, psoriatic) and deforming osteoarthritis. If these diseases are not treated, then over time they lead to the development of a pronounced deformation of the damaged joints, a complete violation 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 you have pain in the phalanges of the fingers, then you should not self-medicate. Only a doctor, after conducting the necessary examination, can make the correct diagnosis and, accordingly, prescribe the necessary therapy.

rice. 127 Upper limb bones ( ossa membri superioris) right; front view.

Finger bones (phalanges), ossa digitorum (phalanges) (see Fig. , , , , ), are presented phalanges, phalanges related in shape to long bones. The first, thumb, finger has two phalanges: proximal, phalanx proximalis, And distal, phalanx distalis. The rest of the fingers have middle phalanx, phalanx media. In each phalanx, a body and two epiphyses are distinguished - proximal and distal.

body, each phalanx is flattened from the front (palmar) side. The surface of the body of the phalanx is limited on the sides by small combs. On it is nutrient hole, continuing into the distally directed nutrient channel.

Superior, proximal, end of phalanx, or base, basis phalangis, thickened and has articular surfaces. The proximal phalanges articulate with the bones of the metacarpus, and the middle and distal phalanges are interconnected.

The lower, distal, end of the 1st and 2nd phalanges has head of the phalanx, caput phalangis.

At the lower end of the distal phalanx, on the back side, there is a slight roughness - tuberosity of the distal phalanx, tuberositas phalangis distalis.

In the area of the metacarpophalangeal joints of the I, II and IV fingers and the interphalangeal joint of the I finger on the palmar surface, in the thickness of the muscle tendons, sesamoid bones, ossa sesamoidea.

rice. 151. Bones of the hand, right (X-ray). 1 - radius; 2 - styloid process of the radius; 3 - lunate bone; 4 - navicular bone; 5 - trapezoid bone; 6 - trapezoid bone; 7-1 metacarpal; 8 - sesamoid bone; 9 - proximal phalanx of the thumb; 10 - distal phalanx of the thumb; 11 - II metacarpal bone; 12 - proximal phalanx of the index finger; 13 - base of the middle phalanx of the index finger; 14 - distal phalanx of the index finger; 15 - capitate bone; 16 - hook of the hook-shaped bone; 17 - hook-shaped bone; 18 - pisiform bone; 19 - trihedral bone; 20 - styloid process of the ulna; 21 - head of the ulna.

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

Structure

The appearance of the phalanges of the fingers and the diagnosis of diseases

Fracture of the phalanx of the finger

Fractures of the phalanges of the fingers most often occur as a result of a direct blow. Fracture of the nail plate of the phalanges is usually always shrapnel.

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

In case of a fracture of the nail phalanx, it is immobilized with a circular plaster bandage or adhesive plaster.

Phalanges of fingers hurt: causes

Even the smallest joints in the human body - interphalangeal joints can be affected by diseases that impair their mobility and are accompanied by excruciating pain. Such diseases include arthritis (rheumatoid, gouty, psoriatic) and deforming osteoarthritis. If these diseases are not treated, then over time they lead to the development of a pronounced deformation of the damaged joints, a complete violation 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 you have pain in the phalanges of the fingers, then you should not self-medicate.. Only a doctor, after conducting the necessary examination, can make the correct diagnosis and, accordingly, prescribe the necessary therapy.

Dislocations of the phalanges of the fingers range from 0.5 to 2% of all hand injuries. Most often, dislocations occur in the proximal interphalangeal joint - about 60%. Approximately with the same frequency, dislocations occur in the metacarpophalangeal and distal interphalangeal joints. Dislocations in the joints of the fingers are more often observed on the right hand in people of working age due to domestic trauma.

Dislocations in the proximal interphalangeal joints. The proximal interphalangeal joint is characterized by two types of damage:

1) rear, anterior, lateral dislocation;

2) fracture-dislocation.

Posterior dislocations occur when hyperextension in the proximal interphalangeal joint. This injury is characterized by rupture of the palmar plate or collateral ligaments.

Lateral dislocations are the result of abductor or adductor forces acting on the finger when the finger is extended. The radial collateral ligament is damaged much more often than the ulnar ligament. As a rule, spontaneous reduction occurs with this damage. The reduction of fresh lateral and posterior dislocations is often not difficult and is performed in a closed way.

Anterior dislocation occurs as a result of combined forces—adductor or abductor—and an anterior force that displaces the base of the middle phalanx anteriorly. In this case, the central bundle of the extensor tendon is separated from the place of attachment to the middle phalanx. Palmar dislocations occur much less frequently than others, since there is a dense fibrous plate in the anterior wall of the capsule, which prevents the occurrence of this damage.

Clinically, with this type of injury in the acute period, swelling and pain may mask the existing deformity or dislocation. In patients with lateral dislocations, the examination shows pain during the rocking test and tenderness on palpation on the lateral side of the joint. Lateral instability indicating a complete tear.

Radiographically, with a rupture of the collateral ligament or with severe swelling, a small fragment of bone is detected at the base of the middle phalanx.

With fracture-dislocations, there is a dorsal subluxation of the middle phalanx with a fracture of the palmar lip of the middle phalanx, which can capture up to 1/3 of the articular surface.

Dislocations in the distal interphalangeal joints.

The distal interphalangeal joints are stable in all positions, since the supporting apparatus consists of dense additional collateral ligaments connected to the fibrous plate from the outer palmar side. Dislocations are also possible here, both in the back and in the palmar side. The reduction of fresh dislocations is not a significant difficulty. The only inconvenience is the short lever for reduction, represented by the nail phalanx. The reduction of chronic dislocations in the interphalangeal joints is much more difficult, since contracture quickly develops with cicatricial changes in the surrounding tissues and the organization of hemorrhage in the joint. Therefore, it is necessary to resort to various methods of surgical treatment.

Dislocations in the metacarpophalangeal joints.

The metacarpophalangeal joints are condylar joints, which, in addition to flexion and extension, have a lateral movement of at least 30 ° when the joint is extended. Because of its shape, this joint is more stable in flexion, when the collateral ligaments are taut, than in extension, which allows lateral movement of the joint. The first finger suffers more often.

With chronic dislocations of the phalanges of the fingers, the main method of treatment is the imposition of compression-distraction devices. Often this method is combined with open reduction. In other cases, if it is impossible to reduce and destroy the articular surfaces, arthrodesis of the joint is performed in a functionally advantageous position. Arthroplasty using biological and synthetic pads is also used.

Treatment of metacarpal fractures

The main methods for restoring the function of the joints of the fingers are open and closed reposition of fragments as soon as possible after injury, arthroplasty using various auto-, homo- and alloplastic materials, treatment with external fixation devices of various designs. Recently, with the development of microsurgical techniques, many authors have proposed the use of vascularized grafts, such as transplantation of a blood-supplying joint, for total and subtotal destruction of the articular surfaces. However, these operations are long, which is unfavorable for the patient, they have a high percentage of vascular complications, and subsequent rehabilitation treatment is difficult due to prolonged immobilization.

In non-surgical treatment of fractures and fracture-dislocations, the most common method is the use of plaster casts, twists and splint-sleeve devices. In clinical practice, immobilization with splints and circular plaster bandages is used. Recently, various types of plastic dressings have been increasingly used.

The terms of immobilization with plaster bandages for fractures and dislocations of the phalanges of the fingers and metacarpal bones of the hand are 4-5 weeks.

When conducting open reposition or reduction of fragments of the phalanges and metacarpal bones of the hand for osteosynthesis, various extraosseous and intraosseous fixators of various sizes are widely used - rods, pins, spokes, screws made of various materials.

Especially great difficulties arise in the treatment of complex intra-articular fractures - both the head and base of the bones in the same joint, with multiple comminuted fractures, accompanied by ruptures of the capsule and ligamentous apparatus of the joint and, as a result, dislocation or subluxation. Often these injuries are accompanied by interposition of bone fragments with blockade of the joint. The authors also offer various methods of treatment: the imposition of external fixation devices, primary arthrodesis of the damaged joint. The most effective surgical treatment, which consists in open reposition and connection of fragments with various fixators.

There is an opinion that in case of severe injuries of the joints of the fingers of the hand, one should not restore the integrity of the articular surfaces, but close the joint by primary arthrodesis, since the creation of a supporting finger when fixing the injured joint in a functionally advantageous position contributes to a faster and more complete rehabilitation of the patient, whose profession is not associated with fine differentiated hand movements. Arthrodesis is widely used for injuries of the distal interphalangeal joints. This operation is also given priority in case of chronic injuries of the joints with significant damage to the articular surfaces.

In the last decade, many technical solutions have been described related to the modernization of existing and the creation of new models of compression-distraction and articulated-distraction devices.

M.A. Boyarshinov developed a method for fixing fragments of the phalanx of the finger with a construction of knitting needles, which is mounted like this. Through the proximal fragment of the phalanx, closer to the base, a Kirschner wire is passed transversely, through the same fragment, but closer to the fracture line, a thin wire is passed, and a pair of thin wires is also passed through the distal fragment. The protruding ends of the Kirschner wire, passed through the proximal fragment at the base of the phalanx, 3-5 mm away from the skin, are bent in the distal direction at an angle of 90° and placed along the finger. At a distance of 1 cm from the distal end of the damaged phalanx, the ends of the spokes are again bent towards each other at an angle of 90° and twisted together. As a result, a single-plane rigid frame is formed. Thin pins are fixed behind it with the effect of compression or distraction of the repaired fragments of the phalanx. Depending on the location and nature of the fracture, the technique for introducing the needles may be different. For transverse and near fractures, we use fixation of fragments at the junction in the form of a lock using L-shaped curved wires according to E.G. Gryaznukhin.

To eliminate the contracture of the fingers in both interphalangeal joints, an external device of the I.G. type can be used. Korshunov, equipped with an additional trapezoidal frame made of Kirchner spokes, and a screw pair on the side of the top of the frame. The external apparatus consists of two arcs with a diameter of 3-3.5 cm, in the area of the ends of the arc there are holes: with a diameter of 0.7-0.8 mm - for conducting knitting needles and with a diameter of 2.5 mm - for threaded rods connecting the arcs to each other. One arc is fixed with a needle to the proximal phalanx, the other to the middle phalanx. A needle is passed through the distal phalanx at the level of the base of the nail, the ends of the needle are bent towards the end of the phalanx and fastened together. The resulting frame is attached to the screw pair of the outer trapezoidal frame. At the same time, a spring can be placed between the screw pair and the frame that fixes the end phalanx for more gentle and efficient traction.

With the help of screw pairs, distraction-extension of the phalanges is performed at a rate of 1 mm/day in the first 4-5 days, then up to 2 mm/day until full extension and creation of diastasis in the interphalangeal joints up to 5 mm. Finger straightening is achieved within 1-1/2 weeks. Distraction of the interphalangeal joints is maintained for 2-4 weeks. and longer depending on the severity and duration of contractures. First, the distal phalanx is released and the distal interphalangeal joint is developed. After restoration of active movements of the distal phalanx, the proximal interphalangeal joint is released. Carry out final rehabilitation measures.

When using surgical treatment and osteosynthesis according to the AO method, an early start of movements in the operated hand is recommended. But in the future, it is necessary to carry out repeated surgical intervention to remove metal structures. At the same time, when fixing fragments with knitting needles, their removal is not technically difficult.

In orthopaedotraumatological practice, only some of the devices with originality and fundamentally significant differences are widely used: Ilizarov, Gudushauri devices, Volkov-Oganesyan articulated and reposition devices, Kalnberz’s “stress” and “rigid” devices, Tkachenko’s “frame” device. Many designs were used only by the authors and have not found wide application in hand surgery.

The main advantage of the Ilizarov apparatus is the variety of layout options, as well as the simple technology for manufacturing the elements of the apparatus. The disadvantages of this apparatus include the multi-subject nature of the kit; the complexity and duration of the processes of assembly, overlay and replacement of elements on the patient; the possibility of fixed displacements in the apparatus; difficulties in eliminating rotational displacements; limited possibilities of accurately controlled and strictly dosed hardware reposition.

When using distraction devices, one should take into account the rather long duration of treatment, the impossibility of complete restoration of the articular surfaces. As a result, the range of their application is limited for various types of damage to the joints of the fingers.

Since the 1940s, metal and plastic structures have been widely used to restore joint mobility, which were used to replace various parts of the joints, articular ends and entire joints. The solution to the problem of endoprosthesis replacement of the joints of the fingers went in two main directions:

development of articulated endoprostheses;

creation of endoprostheses from elastic materials.

An obligatory component in the complex of reconstructive and restorative treatment of patients with injuries of the bones of the hand is postoperative rehabilitation, which includes exercise therapy and a set of physiotherapeutic measures. In restorative treatment, a set of measures is used; recently, phototherapy has been actively used. These procedures help to improve trophism, reduce swelling and pain.

Loss of the first finger leads to a decrease in hand function by 40-50%. The problem of its restoration continues to be relevant today, despite the fact that surgeons have been doing this for more than a hundred years.

The first steps in this direction belong to French surgeons. In 1852, P. Huguier performed the first plastic surgery on the hand, later called phalangization. The meaning of this operation is to deepen the first board-to-board gap without increasing the length of 1 beam. In this way, only the key capture was restored. In 1886, Ouernionprez developed and performed an operation based on a completely new principle - the transformation of the second finger into the I. This operation was called pollicization. In 1898, the Austrian surgeon S. Nicoladom performed the first two-stage transplantation of the second toe. In 1906, F. Krause used the first toe for transplantation, considering it to be more suitable in shape and size, and in 1918, I. Joyce replanted the toe of the opposite hand to replace the lost toe. Methods based on the principle of two-stage transplantation on a temporary pedicle are not widely used due to technical complexity, low functional results, and prolonged immobilization in a forced position.

The method of skin and bone reconstruction of the first finger of the hand is also due to the emergence of C. Nicoladoni, who developed and described in detail the technique of the operation, but for the first time in 1909, the Nicoladoni method was applied by K. Noesske. In our country, V.G. Shchipachev in 1922 performed the phalanging of the metacarpal bones.

B.V. Pariy, in his monograph published in 1944, systematized all methods of reconstruction known at that time and proposed a classification based on the source of the plastic material. In 1980 V.V. Azolov supplemented this classification with new, more modern methods of reconstruction of the first finger: distraction lengthening of the first ray using external fixation devices and microsurgical methods of free transplantation of tissue complexes.

With the development of microsurgery, it became possible to replant completely severed fingers. Obviously, replantation provides the most complete restoration of function, compared with any reconstruction operation, even with shortening and possible loss of movement in the finger joints.

All modern methods of restoring the first finger of the hand can be divided as follows.

plastic with local tissues:

plastic with displaced flaps;

cross plastic;

plasty with flaps on a vascular pedicle:

plastic according to Kholevich;

plastic according to Littler;

radial rotated flap;

2) remote plasty:

on a temporary feeding leg:

sharp Filatov stem;

plastic according to Blokhin-Conyers;

free transplantation of tissue complexes with microsurgical technique:

flap of the first interdigital space of the foot;

other blood-supplying tissue complexes.

Methods restoring segment length:

heterotopic replantation;

pollicization;

2nd toe transplant:

transplantation of segment I toe.

Methods that do not increase segment length:

phalangization.

Methods that increase the segment length:

1) methods using tissues of the injured hand:

distraction lengthening of the segment;

pollicization;

skin and bone reconstruction with a radially rotated skin and bone flap;

2) distant plasty with the help of free transplantation of tissue complexes using microsurgical technique:

transplantation of the finger of the opposite hand;

transplantation of the second toe;

transplantation of segment III toe;

one-stage skin and bone reconstruction using a free skin and bone flap.

The criteria for primary and secondary recovery is the time elapsed since the injury. The permissible periods in this case are the deadlines during which replantation is possible, i.e. 24 hours.

The main requirements for the restored first finger are as follows:

sufficient length;

stable skin;

sensitivity;

mobility;

acceptable appearance;

growth ability in children.

The choice of the method of its restoration depends on the level of loss; in addition, gender, age, profession, the presence of injuries to other fingers of the hand, the state of health of the patient, as well as his desire and the capabilities of the surgeon are taken into account. It is traditionally believed that the absence of the nail phalanx of the 5th finger is a compensated injury and surgical treatment is not indicated. However, the loss of the nail phalanx of the first finger is the loss of 3 cm of its length, and, consequently, a decrease in the functional ability of the finger and hand as a whole, namely, the inability to capture small objects with the fingertips. In addition, nowadays more and more patients want to have a full-fledged brush in aesthetic terms. The only acceptable reconstruction method in this case is the transplantation of part I of the finger.

The length of the 1st ray stump is a determining factor in choosing the method of surgical treatment.

In 1966, in the USA, H. Buncke for the first time performed a successful simultaneous transplantation of the first toe to the hand in a monkey with the imposition of microvascular anastomoses, and Cobben in 1967 was the first to perform such an operation in the clinic. Over the next two decades, the technique of performing this operation, indications, contraindications, functional results and consequences of borrowing the first toe from the foot were studied in detail by many authors, including those in our country. Studies have shown that in functional and cosmetic terms, the 1st toe almost completely corresponds to the 1st toe. As for the function of the donor foot, here the opinions of surgeons differ. N. Buncke et al. and T. Mau, having performed biomechanical studies of the feet, came to the conclusion that the loss of the first toe does not lead to significant gait limitations. However, they noted that prolonged healing of the donor wound is possible due to poor engraftment of a free skin graft, and the formation of rough hypertrophic scars on the back of the foot is also possible. These problems, according to the authors, can be minimized by following the rules of precision technique when isolating the toe and closing the donor defect, as well as with proper postoperative management.

Special studies conducted by other authors have shown that in the final stage of the step on the first finger, up to 45% of body weight falls. After amputation, it may cause lateral instability of the medial part of the foot due to dysfunction of the plantar aponeurosis. So, when the main phalanx of the first finger is displaced to the position of dorsiflexion, the weight of the body moves to the head of the first metatarsal bone. In this case, the plantar aponeurosis is stretched, and the interosseous muscles through the sesamoid bones stabilize the metatarsophalangeal joint and raise the longitudinal arch of the foot. After the loss of the first toe, and especially the base of its proximal phalanx, the effectiveness of this mechanism decreases. The load axis shifts laterally to the heads of the II and III metatarsal bones, which in many patients leads to the development of metatarsalgia. Therefore, when taking the first finger, it is advisable to either leave the base of its proximal phalanx, or firmly hem the tendons of the short muscles and the aponeurosis to the head of the first metatarsal bone.

Buncke toe transplant I

preoperative planning.

The preoperative examination should include a clinical assessment of the blood supply to the foot: determination of arterial pulsation, dopplerography and arteriography in two projections. Angiography helps to document the adequate blood supply to the foot from the posterior tibial artery. In addition, hand arteriography should be performed if there is any doubt about the condition of potential recipient vessels.

The dorsalis pedis artery is a continuation of the anterior tibial artery that runs deep under the suspensory ligament at the level of the ankle joint. The dorsal artery of the foot is located between the tendons m. extensor hallucis longus medially and so on. extensor digitorum longus laterally. The artery is accompanied by committed veins. The deep peroneal nerve is located lateral to the artery. Passing over the bones of the tarsus, the dorsal artery of the foot gives off the medial and lateral tarsal arteries and forms an arterial arch in the region of the base of the metatarsal bones, which runs in the lateral direction. The second, third and fourth dorsal metatarsal arteries are branches of the arterial arch and pass along the dorsal surface of the corresponding dorsal interosseous muscles.

The first dorsal metatarsal artery is a continuation of the dorsal artery of the foot. It is usually located on the dorsal surface of the first dorsal interosseous muscle and supplies blood to the skin of the dorsal foot, I and II metatarsal bones and interosseous muscles. In the region of the first interdigital space, the first dorsal metatarsal artery divides into at least two branches, one of which runs deep to the tendon of the long extensor of the first finger, supplying the medial surface of the first toe, and the other branch supplies the adjacent sides of the first and second toes.

The deep plantar branch departs from the dorsal artery of the foot at the level of the base of the I metatarsal bone and goes to the plantar surface of the foot between the heads of the first dorsal interosseous muscle. It connects with the medial plantar artery and forms the plantar arterial arch. The deep plantar artery also gives off branches to the medial side of the first toe. The first plantar metatarsal artery is a continuation of the deep plantar artery, which is located in the first intermetatarsal space and supplies blood to the adjacent sides of the I and II toes from the plantar side.

According to a group of studies, the dorsal artery of the foot is absent in 18.5% of cases. Nutrition from the system of the anterior tibial artery is carried out in 81.5% of cases. Of these, 29.6% have a predominantly dorsal type of blood supply, 22.2% have a predominantly plantar type, and 29.6% have a mixed type. Thus, in 40.7% of cases there was a plantar type of blood supply to the I and II toes.

Venous outflow is carried out through the veins of the rear of the foot, which flow into the dorsal venous arch, which forms the large and small saphenous systems. Additional outflow occurs through the veins that accompany the dorsal artery of the foot.

The dorsal surface of the toes is innervated by the superficial branches of the peroneal nerve, and the first interdigital space is innervated by the branch of the deep peroneal nerve and the plantar surface of the I-II fingers is innervated by the digital branches of the medial plantar nerve. All these nerves can be used to reinnervate the transplanted complexes.

Usually, a toe is used on the same side, especially if additional skin plastic is needed to cover the toe on the hand, which can be taken from the foot along with the transplanted toe. The problem of soft tissue deficiency in the recipient area can be solved by traditional plasty methods, such as free skin grafting, pedunculated flap plasty, free tissue complex grafting before or during finger reconstruction.

Isolation on the foot

Before surgery, the course of the great saphenous vein and dorsal artery on the foot is marked. A tourniquet is applied to the shin. On the back of the foot, a straight, curved or zigzag incision is made along the dorsal artery of the foot, preserving the saphenous veins, the dorsal artery of the foot and its continuation - the first dorsal metatarsal artery. If the first dorsal metatarsal artery is present and located superficially, then it is traced in the distal direction and all side branches are tied up. If the dominant artery is the plantar metatarsal artery, then the exposure is started from the first interdigital space in the proximal direction, by making a longitudinal incision on the sole for a wider view of the metatarsal head. Isolation in the proximal direction is continued until an artery of sufficient length is obtained. Sometimes it is necessary to cut the transverse intertarsal ligament to mobilize the plantar metatarsal artery. If it is impossible to determine which of the vessels is dominant, then the extraction is started in the first intermetatarsal space and performed in the proximal direction. In the first interdigital space, the artery is ligated to the second finger and the first intermetatarsal artery is traced until it becomes clear how to isolate it - from the dorsal or plantar access. The vascular bundle is not crossed until the possibility of blood supply to the finger through it is verified and the preparation of the hand for transplantation is completed.

The dorsal artery of the foot is traced to the short extensor of the first finger, crossed, raised and the deep peroneal nerve located lateral to the dorsal artery of the foot is opened. The deep peroneal nerve is isolated to restore it with the recipient nerve on the hand. The first metatarsal artery is traced to the interdigital space, keeping all the branches going to the first finger, and bandaging the rest. Allocate and mobilize superficial veins so as to obtain a long venous stalk. In the first interdigital space, the plantar digital nerve is isolated along the lateral surface of the finger and separated from the digital nerve leading to the second finger by carefully dividing the common digital nerve. In the same way, the plantar nerve is isolated on the medial surface of the first finger and mobilized as much as possible. The length of the exposed nerves depends on the requirements of the recipient area. Sometimes a nerve graft may be required. Determine the approximate required length of the tendons on the hand. The tendon of the long extensor of the first finger is crossed at the level of the suspensory ligament or proximal if necessary. To highlight the tendon of the long flexor of sufficient length, an additional incision is made on the sole. At the level of the sole, between the tendon of the long flexor of the first finger and the flexor tendons of other fingers, there are jumpers that prevent it from being isolated from the incision behind the ankle. The finger is isolated from the metatarsophalangeal joint. If it is necessary to restore the metacarpophalangeal joint on the hand, then you can take the joint capsule together with your finger.

The plantar surface of the head of the first metatarsal bone should be preserved, but the back of it can be taken with a finger if an oblique osteotomy of the head is made. After removing the tourniquet, hemostasis is carefully performed on the foot. After tying the graft vessels and crossing them, the finger is transferred to the hand. The wound on the foot is drained and sutured.

Brush preparation.

The operation begins with the imposition of a tourniquet on the forearm. Two incisions are usually required to prepare the recipient site. A curved incision is made from the dorsal-radial surface of the stump of the first finger through the palm along the tenar fold, and, if necessary, it is extended to the distal part of the forearm, opening the carpal tunnel. An incision is made along the back of the hand in the projection of the anatomical snuffbox, continuing it to the end of the finger stump. The tendons of the long and short extensors of the first finger, the long abductor muscle of the first finger, the cephalic vein and its branches, the radial artery and its terminal branch, the superficial radial nerve and its branches are isolated and mobilized.

Allocate the stump of the first finger. From the palmar incision, the digital nerves to the 1st finger, the tendon of the long flexor, the adductor 1st finger muscle and the short abductor muscle are mobilized, if possible, as well as the palmar digital arteries, if they are suitable for anastomosis. Now remove the tourniquet and perform a thorough hemostasis.

Actually transplantation of the toe to the hand.

The base of the main phalanx of the toe and the stump of the main phalanx of the toe are adapted, and osteosynthesis is performed with Kirschner wires.

The flexor and extensor tendons are repaired in such a way as to balance the forces on the transplanted toe as much as possible. T. Mau et al. proposed a scheme for tendon reconstruction.

The inflow through the recipient radial artery is checked, and anastomosis is made between the dorsal artery of the foot and the radial artery.

Impose an anastomosis on the head vein and the great saphenous vein of the foot. Usually one arterial and one venous anastomosis is sufficient. The lateral plantar nerve of the toe and the ulnar digital nerve of the toe are sutured epineurally, as well as the medial plantar nerve of the toe with the radial nerve of the toe. If possible, the superficial branches of the radial nerve can be sutured to a branch of the deep peroneal nerve. The wound is sutured without tension and drained with rubber graduates. If necessary, plasty with a free skin graft is used. Immobilization is performed with a plaster longet bandage in such a way as to avoid compression of the transplanted finger in the bandage and to ensure control over the state of its blood supply.

Transplantation of a fragment of the first toe

In 1980, W. Morrison described a free vascularized complex tissue complex from the 1st toe, "wrapping" a traditional non-vascularized bone graft from the iliac crest for the reconstruction of the lost 1st toe.

This flap includes the nail plate, dorsal, lateral and plantar skin of the first toe and is considered to be indicated for the reconstruction of the first toe in case of loss at or distal to the metacarpophalangeal joint.

The advantages of this method are:

restoration of the length, full size, sensitivity, movement and appearance of the lost finger;

only one operation is required;

preservation of the toe skeleton;

minimal gait disturbance and minor damage to the donor foot.

The disadvantages are:

the need for the participation of two teams;

potential loss of the entire flap due to thrombosis;

the possibility of bone resorption;

the absence of the interphalangeal joint of the reconstructed finger;

the possibility of prolonged healing of the donor wound due to rejection of a free skin graft;

inability to use it in children due to lack of growth ability.

As with all microvascular foot surgery, the adequacy of the first dorsal metatarsal artery must be assessed prior to surgery. In those feet where it is absent, a plantar approach may be required to isolate the first plantar metatarsal artery. Before the operation, it is necessary to measure the length and circumference of the first finger of a healthy hand. Use the toe on the same side to ensure suturing of the lateral plantar nerve with the ulnar digital nerve of the hand. Two surgical teams are involved to expedite the operation. One team isolates the complex on the foot, while the other prepares the hand, takes the bone graft from the iliac crest and performs its fixation.

Operation technique

A skin-fat flap is isolated so that the entire first toe is skeletonized, with the exception of a strip of skin on the medial side and distal tip of the toe. The distal end of this strip should extend almost to the lateral edge of the nail plate. The width of this band is determined by the amount of skin required to fit the size of a normal I finger. A 1 cm wide strip is usually left. The flap should not extend too proximally to the base of the first toe. Leave enough skin in the interdigital space to be able to sew up the wound. The direction of the first dorsal metatarsal artery is marked. Lowering the foot and using a venous tourniquet, mark suitable dorsal veins of the foot.

Perform a longitudinal incision between the I and II metatarsal bones. The dorsal artery of the foot is identified. Then it is isolated distally to the first dorsal metatarsal artery. If the first dorsal metatarsal artery is located deep in the intermetatarsal space, or if the plantar digital artery is dominant for the first toe, a plantar incision is made in the first interdigital space. Allocate the lateral digital artery in the first interdigital space, and continue to allocate it proximally through a linear incision. Bandage the vascular branches to the second toe, keeping all the branches to the flap. A branch of the deep peroneal nerve is traced, which runs next to the lateral digital artery to the first toe, and the nerve is divided proximally so that its length meets the requirements of the recipient zone.

The dorsal veins leading to the flap are isolated. Lateral branches are coagulated to obtain a vascular pedicle of the required length. If the plantar metatarsal artery is used, it may be necessary to plasty it with a venous graft to obtain a vascular pedicle of the required length.

Once the neurovascular pedicle has been exposed, a transverse incision is made at the base of the toe, avoiding damage to the vein draining the flap. The toe flap is raised, unfolded, and the lateral plantar neurovascular bundle is identified. The medial neurovascular bundle is isolated and mobilized, maintaining its connection with the medial skin flap.

Separate the toe flap under the nail plate by careful subperiosteal exposure, avoiding damage to the matrix of the nail plate. Remove with a flap about 1 cm tuberosity of the nail phalanx under the nail plate. The parathenon is kept on the tendon of the long extensor of the first finger in order to make it possible to perform the plastic surgery with a free split skin graft. Raise the plantar part of the flap, leaving the subcutaneous tissue on the plantar surface of the finger. The lateral plantar digital nerve is cut off from the common digital nerve at the appropriate level. If the lateral plantar digital artery is not the main feeding artery of the flap, then se coagulate and cross.

At this stage, the flap retains its connection with the foot only due to the vascular bundle, which consists of the dorsal digital artery, which is a branch of the first dorsal metatarsal artery, and veins that flow into the system of the great saphenous vein of the leg. Remove the tourniquet, and make sure that the flap is supplied with blood. It may take 30 to 60 minutes to restore blood flow to the flap. Wrapping with a cloth soaked in warm isotonic sodium chloride solution or lidocaine solution can help stop persistent vasospasm. When the flap turns pink and the hand preparation is complete, microclips are applied to the vessels, ligated and transected. The plasty of the first toe is carefully performed with a split skin graft. Removal of 1 cm of the distal phalanx allows the tip of the finger to be wrapped with a medial skin flap. The plantar, dorsal and lateral surfaces of the finger are covered with a free split skin graft. W. Morrison suggested using cross plasty to cover the donor defect on the first toe, but usually it is not required.

Brush preparation.

The hand preparation team should also take the iliac crest cancellous-cortical graft and process it to fit a healthy finger. Normally, the tip of the first finger of the hand in adduction to the second finger is 1 cm proximal to the proximal interphalangeal joint of the second finger. On the brush, two zones require preparation. This is the dorsal-radial surface slightly distal to the anatomical snuffbox and directly the amputation stump. A longitudinal incision is made under the tourniquet in the first interdigital space. Two or more dorsal hand veins are isolated and mobilized. A. is mobilized between the first dorsal interosseous muscle and the adductor muscle of the first finger. radialis. Identify the superficial radial nerve. The arterial pedicle is mobilized, dissecting it proximally to the level of the proposed anastomosis at the level of the metacarpal or metacarpophalangeal joint.

The skin on the stump of the first finger is dissected with a straight incision across its tip from the mid-medial to mid-lateral line, highlighting the dorsal and palmar subperiosteal flap about 1 cm in size. The neuroma of the ulnar digital nerve is isolated and excised. Refresh the end of the stump for osteosynthesis with a graft. A recess is created in the stump of the main phalanx of the first finger or in the metacarpal bone in order to place it in a bone graft and then fix it with Kirschner wires, a screw or a miniplate with screws. The flap is wrapped around the bone so that its lateral side lies on the ulnar side of the bone graft. If the bone graft is too large, then it must be reduced to the required size. The flap is fixed with interrupted sutures in place so as to position the nail plate dorsally and the neurovascular bundle in the first intermetacarpal space. Using optical magnification, an epineural suture is applied to the ulnar digital nerve of the 1st finger of the hand and the lateral plantar nerve of the toe with a 9/0 or 10/0 thread. The own digital artery of the finger is sutured to the first dorsal metatarsal artery of the flap. The arterial inflow is restored, and the dorsal veins are sutured. The deep peroneal nerve is sutured to a branch of the superficial radial nerve. The wound is sutured without tension, and the space under the flap is drained, avoiding placing the drain near the anastomoses. Then apply a loose bandage and plaster so as not to squeeze the finger, and leave the end of it to monitor the blood supply.

Postoperative management is carried out according to the usual technique developed for all microsurgical operations. Active finger movements begin after 3 weeks. As soon as the wound on the foot heals, the patient is allowed to walk with support on the foot. Special footwear is not required.

Osteoplastic reconstruction of the finger

Complex insular radial forearm flap.

This operation has the following advantages: good blood supply to the skin and bone graft; the working surface of the finger is innervated by transplanting the islet flap on the neurovascular pedicle; one-step method; there is no resorption of the bone part of the graft.

The disadvantages of the operation include a significant cosmetic defect after taking the flap from the forearm and the possibility of a fracture of the radius in the distal third.

Before the operation, angiography is performed to determine the viability of the ulnar artery and the superficial palmar arch, which provides blood supply to all fingers of the injured hand. Identification of the predominant blood supply due to the radial artery or the absence of the ulnar artery excludes the possibility of performing this operation in the author's version, but a free transplantation of a complex of tissues from a healthy limb is possible.

The operation is performed under a tourniquet. The flap is lifted from the palmar and dorsal-radial surface of the forearm, its base is located a few centimeters proximal to the styloid process of the radius. The flap should be 7-8 cm long and 6-7 cm wide. After preparing the distal part of the stump of the first finger, the flap is raised based on the radial artery and its comitant veins. Special care must be taken not to injure the cutaneous branches of the radial nerve or disrupt the blood supply to the radius just proximal to the styloid process. Small branches of the radial artery leading to the pronator quadratus muscle and further to the periosteum of the radius are identified. These vessels are carefully mobilized and protected, followed by an osteotomy of the radius and elevation of the radius fragment using bone instruments. The length of the graft may vary depending on the length of the stump of the first finger and the planned lengthening. The bone graft must include a corto-cancellous fragment of the lateral surface of the radius at least 1.5 cm wide, and it must be raised so that vascular connections to the flap are preserved. The radial vessels are ligated proximally, and the entire flap is mobilized as a complex complex to the level of an anatomical snuffbox. The tendon of the long abductor muscle of the first finger and the short extensor of the first finger is released proximally by dissecting the distal part of the first dorsal supporting ligament. A complex skin and bone graft is then carried out under these tendons to the rear to the distal wound of the stump of the first finger. The bone graft is fixed with the spongy part of the I metacarpal bone in the position of opposition to the II finger. Fixation is carried out longitudinally or obliquely with knitting needles, or a mini-plate is used. The distal end of the graft is processed to give it a smooth shape. The skin portion of the flap is then wrapped around the graft and the rest of the metacarpal or proximal phalanx.

At this stage, an islet flap on a vascular pedicle is lifted from the ulnar side of the III or IV finger and placed on the palmar surface of the bone graft to provide sensitivity. A full-thickness skin graft is used to cover the donor finger defect. A split or full-thickness skin graft is taken from the anterior thigh to cover the donor area of the forearm after covering the radius defect with muscles. After removing the tourniquet, it is necessary to control the blood supply to both flaps and, in the presence of any problems, perform revision of the vascular pedicle.

A plaster cast is applied, and sufficient areas of the flaps are left open to ensure constant monitoring of their blood supply. Immobilization is maintained for 6 weeks or more until signs of consolidation appear.

Second toe transplant.

The first successful transplantation of the second toe into the position of the second toe was performed by Chinese surgeons Yang Dong-Yue and Chen Zhang-Wei in 1966. and the second plantar metatarsal arteries, extending from the deep plantar arch. The first dorsal metatarsal artery passes through the first intermetatarsal space. Here it is divided into the dorsal digital arteries, going to the I and II fingers. The deep branch of the dorsal artery of the foot runs between the I and II metatarsal bones, connecting with the lateral plantar artery, and forms a deep plantar arch. The first and second plantar metatarsal arteries arise from the deep plantar arch. At the plantar surface of each interdigital space, the plantar artery bifurcates and forms the plantar digital arteries to adjacent fingers. In the first interdigital space there are digital vessels of the I and II fingers. Transplantation of the second toe is carried out either on the first dorsal metatarsal artery, extending from the dorsal artery of the foot, as a feeding artery, or on the first plantar metatarsal artery, extending from the deep plantar arch. There are variants of the anatomy of the vessels of the toes, in which the second toe is supplied with blood mainly from the system of the dorsal artery of the foot and the plantar arch. Depending on the anatomical features, the selection of a toe on the foot can be simple or complex. Based on the technique proposed by C.Poncber in 1988, a method was developed for isolating the second toe on the foot, which allows all vessels feeding the second toe to be isolated from the back access.

Isolation of the graft on the foot. For transplantation, a finger from the same side is preferable, since normally the toes on the foot have a deviation to the lateral side, and therefore it is easier to orient the transplanted finger to long fingers. Before the operation, the pulsation of the dorsal artery of the foot is determined and the course of the artery and the great saphenous vein is marked. Then a tourniquet is applied to the limb.

On the back of the foot, a curved incision is made in the projection of the dorsal artery of the foot and the first intermetatarsal space. At the base of the second finger, a fringing incision is made with cutting out triangular flaps along the rear and plantar surface of the foot. The size of the cut patches can be different. After separating the skin and providing wide access to the dorsal structures of the foot, veins are carefully isolated - from the great saphenous vein at the level of the ankle joint to the base of the triangular flap at the second finger. The tendon of the short extensor of the first finger is crossed and retracted, after which the dorsal artery of the foot is isolated along the required length proximally and distally to the base of the first metatarsal bone. At this level I define! the presence of the first dorsal metatarsal artery and its diameter. If the first dorsal metatarsal artery is more than 1 mm in diameter, then it must be traced to the base of the second finger. After isolation and intersection of the extensor tendons of the second finger, a subperiosteal osteotomy of the second metatarsal bone is performed in the region of its base, the interosseous muscles are peeled off, and the second metatarsal bone is raised by flexion at the metatarsophalangeal joint. This allows you to open wide access to the plantar vessels and trace the deep branch connecting the dorsal artery of the foot with the plantar arch. From the plantar arch, the plantar metatarsal arteries leading to the II finger are traced and evaluated. Usually the medial plantar digital artery of the second finger is of large diameter and departs from the first plantar metatarsal artery in the first interdigital space perpendicular to the axis of the finger. With this variant of anatomy, the first plantar metatarsal artery, departing from the plantar arch, goes in the first intermetatarsal space and goes under the head of the first metatarsal bone, where, giving off lateral branches, it goes to the plantar surface of the first finger. It can be isolated only after the intersection of the intertarsal ligament and muscles attached to the lateral side of the head of the first metatarsal bone. The selection is facilitated by the tension of the vessel, taken on a rubber holder. After mobilization of the artery, the branches leading to the first finger are coagulated and crossed. If necessary, the second plantar metatarsal artery can be isolated, running in the second intermetatarsal space. Then, the common toe plantar nerves are isolated, the bundles leading to the adjacent fingers are separated, and the digital nerves of the second finger are crossed. The tendons of the flexors of the II finger are isolated, and they are crossed. After crossing the vessels leading to the III finger, the II finger remains connected to the foot only by an artery and a vein. They take off the tourniquet. It is necessary to wait for the complete restoration of blood flow in the finger.

Selection on the brush. A tourniquet is applied to the forearm. An incision is made through the end of the stump of the 1st ray with a continuation to the rear and palmar surface of the hand. Select all structures that need to be restored:

dorsal saphenous veins;

extensors of the first finger;

tendon of the long flexor of the first finger;

palmar digital nerves;

recipient artery;

remove scars and the endplate of the stump of the 1st beam.

After removing the tourniquet, the presence of inflow through the recipient artery is checked.

Transplantation of the graft to the hand. The graft is prepared for osteosynthesis. This moment of the operation depends on the level of the defect of the first finger. When the I metacarpophalangeal joint is preserved, the II metatarsal bone is removed and the cartilage and cortical plate of the base of the main phalanx of the II finger are removed. In the presence of a stump at the level of the metacarpophalangeal joint, 2 options are possible - joint restoration and arthrodesis. When performing arthrodesis, the preparation of the graft is performed as described above. When restoring the joint, an oblique osteotomy of the metatarsal bone is performed under the head at the level of attachment of the metatarsophalangeal joint capsule at an angle of 130°, open to the plantar side. This eliminates the tendency to hyperextension in the joint after finger-to-hand transplantation, since the metatarsophalangeal joint is anatomically an extensor joint. In addition, this osteotomy allows you to increase the amount of flexion in the joint.

If there is a stump of the first finger at the level of the metacarpal bone, the part of the metatarsal bone necessary along the length is left as part of the graft. After preparing the graft, osteosynthesis is performed with Kirschner wires. Additionally, we fix the distal interphalangeal joint of the second finger in extension with a pin to exclude the possibility of developing a flexion contracture of the finger. When performing osteosynthesis, it is necessary to orient the transplanted finger to the existing long fingers in order to be able to perform a pinch grip. Next, the extensor tendons are sutured, while the prerequisite is the position of full extension of the finger. The flexor tendons are then sutured. The suture is applied with slight tension on the central end of the tendon of the long flexor to avoid the development of flexion contracture of the finger. Then anastomoses of the artery and vein are performed and the nerves are sutured epineurally. When suturing the wound, it is necessary to avoid skin tension to exclude the possibility of vascular compression. When transplanting a finger with a metatarsophalangeal joint, it is most often not possible to cover the lateral surfaces in the joint area. In such a situation, plasty with a free full-thickness skin graft is most often used. Rollers are not fixed to these grafts.

If there is a cicatricial deformity in the area of the stump of the 1st ray on the hand or a finger and metatarsal bone transplantation is planned, then additional skin grafting may be required, which can be performed either before the finger transplantation or at the time of the operation. Immobilization is carried out with a plaster splint bandage.

Sewing up a donor wound on the foot. After careful hemostasis, the intertarsal ligament is restored and the crossed muscles are sutured to the first finger. The metatarsal bones are brought together and fixed with Kirschner wires. After that, the wound is easily sutured without tension. Drain the space between the I and II metatarsal bones. Immobilization is carried out with a plaster splint bandage along the back surface of the lower leg and foot.

Postoperative management is carried out, as in any microsurgical operation.

The immobilization of the hand is kept until the onset of consolidation, on average 6 weeks. From the 5th-7th day after the operation, you can start careful active movements of the transplanted finger in a bandage under the supervision of a doctor. After 3 weeks, the pin fixing the distal interphalangeal joint is removed. The immobilization of the foot is carried out for 3 weeks, after which the needles are removed, the plaster cast is removed. Within 3 months after surgery, the patient is not recommended to fully load the leg. Within 6 months after surgery, it is recommended to bandage the foot to prevent flattening of the forefoot.

pollicization

The operation of tissue transposition, which turns one of the fingers of the damaged hand into the I finger, has more than a century of history.

The first report of true pollicization of the second finger with exposure of the neurovascular bundle and a description of the grafting technique belongs to Gosset. A necessary condition for successful pollicization is the departure of the corresponding common palmar digital arteries from the superficial arterial arch.

Anatomical studies have established that in 4.5% of cases, some or all of the common digital arteries depart from the deep arterial arch. In this case, the surgeon must choose a donor finger, to which the common palmar digital arteries depart from the superficial arterial arch. If all the common palmar digital arteries arise from the deep arterial arch, then the surgeon can transpose the second finger, which, unlike other fingers, can be moved in this case as well.

pollicization of the 2nd finger. Under the tourniquet, flaps are planned around the base of the second finger and over the second metacarpal bone. A racket-shaped incision is made around the base of the second finger, starting from the palm at the level of the proximal digital crease and continuing around the finger, connecting to a V-shaped incision above the middle part of the metacarpal bone with a bend extending to the base of the metacarpal bone, where it deviates laterally to the area of the stump I metacarpal bone.

Skin flaps are carefully isolated, and the remnants of the II metacarpal bone are removed. On the palm, neurovascular bundles are isolated to the second finger and flexor tendons. The digital artery to the radial side of the third finger is identified and transected behind the bifurcation of the common digital artery. Perform a thorough separation of the bundles of the common finger nerve to the II and III fingers.

On the back, several dorsal veins are isolated to the second finger, mobilized by tying up all the side branches that interfere with its movement. Cross the transverse intermetacarpal ligament, and separate the interosseous muscles. The extensor tendons of the II finger are mobilized. Further, the course of the operation varies depending on the length of the stump of the first beam. If the saddle joint is preserved, then the II finger is isolated in the metacarpophalangeal joint and the base of the main phalanx is resected, so the main phalanx of the II finger will perform the function of the I metacarpal bone. If the saddle joint is absent, only the polygonal bone is preserved, then the metacarpal bone is resected under the head, so the II metacarpophalangeal joint will perform the function of the saddle joint. The second finger now remains on the neurovascular bundles and tendons and is ready for transplantation.

Prepare the I metacarpal bone or, if it is small or absent, a polygonal bone for osteosynthesis. The medullary canal of the stump of the I metacarpal or trapezoid bone is expanded, and a small bone pin, taken from the removed part of the II metacarpal bone, is inserted into the base of the proximal phalanx of the II finger, as soon as it is transferred to a new position, and fixed with Kirschner wires. It is important to position the finger to be moved in sufficient abduction, opposition, and pronation. If possible, the extensor tendons of the second finger are sutured to the mobilized stump of the long extensor of the first finger. Since the II finger is noticeably shortened, it may sometimes be necessary to shorten the flexor tendons to the II finger. The tourniquet is removed, the viability of the displaced finger is assessed. The skin wound is sutured after moving the lateral flap of the interdigital space into a new split between the moved finger and the third finger.

The immobilization of the 1st beam is kept for 6-8 weeks, until the onset of fusion. Additional surgical interventions are possible, including shortening of the flexor tendons, extensor tenolysis, opponenoplasty, if the thenar muscle function is lost and satisfactory rotational movements in the saddle joint are preserved.

pollicization of the 4th finger.

Under the tourniquet, a palmar incision is started at the level of the distal palmar fold, continues on each side of the fourth finger through the interdigital spaces and is connected distally above the fourth metacarpal bone approximately at the level of its middle. Further, the incision is continued to the base of the IV metacarpal bone.

The flaps are separated and lifted, and through the palmar incision, the neurovascular bundles are identified and mobilized. Ligation of the ulnar digital arterial branch to the III finger and the radial digital arterial branch to the V finger is performed slightly distal to the bifurcation of the common digital artery in the third and fourth interdigital spaces, respectively. Under a microscope, the general digital nerves are carefully split to the III and IV fingers and to the IV and V fingers, which is required to carry out the movement of the finger through the palm without tension on the digital nerves or damage to the nerves to the III and V fingers.

The transverse intermetacarpal ligaments are dissected on each side, leaving sufficient length so that the two ligaments can be connected after the fourth finger transplant. The extensor tendon of the fourth finger is transected at the level of the base of the fourth metacarpal and mobilized distally to the base of the proximal phalanx. The metacarpal bone is freed from the interosseous muscles attached to it, and the tendons of the short muscles to the IV finger are crossed distally. Then, an osteotomy of the IV metacarpal bone is performed at the level of the base and it is removed. The flexor tendons are mobilized to the middle of the palm, and any remaining soft tissues attached to the fourth finger are transected in preparation for passing it through the subcutaneous tunnel in the palm.

The first metacarpal bone is prepared for transplantation of the fourth finger, and if it is short or absent, then the articular surface of the polygonal bone is removed to the spongy substance. It is possible to make a channel in the I metacarpal or in the trapezoid bone for the introduction of a bone pin when fixing the transplanted finger. An incision is made along the rear of the first metacarpal bone in the proximal direction to identify and mobilize the tendon stump of the long extensor of the first finger. Remove scars in the area of the stump of the first finger, leaving a well-perfused skin to cover the brine after finger transplantation.

A tunnel is formed under the skin of the palmar surface of the hand for holding the IV finger to the stump of the I ray. The finger is carefully passed through the tunnel. In its new position, the finger is rotated 100° along the longitudinal axis to achieve a satisfactory position with minimal tension on the neurovascular bundles. The articular surface of the proximal phalanx of the IV finger is removed, and the bone is modeled to obtain the required finger length. Fixation is carried out with Kirschner wires. The use of a bone intramedullary nail through the site of bone contact is not necessary.

The operation is completed by suturing the extensor tendon of the fourth finger with the distal stump of the long extensor of the first finger. The tendon suture is performed with sufficient tension until full extension of the fourth finger in the proximal and distal interphalangeal joints is obtained. The rest of the tendon of the short muscle abducting finger I is connected to the rest of the tendons of the interosseous muscles of the fourth finger from the radial side. Sometimes it is possible to sew the remnant of the tendon of the adductor muscle to the tendon stumps of the short muscles on the ulnar side of the transplanted finger. Since the outflow of blood is carried out mainly through the dorsal veins, and when the finger is removed and passed through the tunnel, they must be crossed, it is often necessary to restore venous outflow by suturing the veins of the transplanted finger with the veins of the dorsal hand in a new position. Then the tourniquet is removed to control blood supply and hemostasis.

The suturing of the donor wound is carried out after the restoration of the transverse intermetacarpal ligament of the III and V fingers.

In the first interdigital space, the wound is sutured so that there is no splitting of the hand. When suturing the wound at the base of the transplanted finger, several Z-plasty may be required to prevent the formation of a circular pressure scar that disrupts the blood supply to the transplanted finger.

Immobilization is maintained until bone union, approximately 6-8 weeks. The movements of the IV finger begin after 3-4 weeks, although with fixation with a plate, movements can be started earlier.

Method of two-stage pollicization.

It is based on the “prefabrication” method, which consists in a staged microsurgical transplantation of a blood-supplying complex of tissues, including a vascular bundle with its surrounding fascia, into a proposed donor area to create new vascular connections between this vascular bundle and the future tissue complex. The fascia surrounding the vascular bundle contains a large number of small vessels, which, by the 5-6th day after transplantation, grow into the surrounding tissues and form connections with the vascular network of the recipient area. The "prefabrication" method allows you to create a new vascular bundle of the required diameter and length.

Two-stage pollicization may be indicated in the presence of injuries to the hand that preclude classical pollicization due to damage to the superficial arterial arch or common digital arteries.

Operation technique. The first stage is the formation of the vascular pedicle of the selected donor finger. Brush preparation. Excised scars on the palm. An incision is made along the palmar surface of the main phalanx of the donor finger, which is connected to the incision in the palm. Then a small longitudinal incision is made along the rear of the main phalanx of the donor finger. Carefully exfoliate the skin along the lateral surfaces of the main phalanx of the finger to form a bed for the fascia of the flap. Next, an incision is made in the projection of the future recipient vessels in the area of the "anatomical snuffbox". The recipient vessels are mobilized and prepared for anastomosis.

Fascial flap formation. A radial skin-fascial flap is used from the other limb in order to, in addition to forming the vascular pedicle of the donor finger, in order to replace the defect in the palmar surface of the hand. Any fascial flap with an axial type of blood supply can be used. The details of the operation are known. The length of the vascular pedicle of the flap is determined in each specific case by measuring from the edge of the defect or the base of the donor finger, if there is no defect, then to the recipient vessels.

Formation of the vascular pedicle of the donor finger. The flap is placed on the palm of the injured hand so that the distal fascial part of the flap is passed under the skin of the main phalanx of the donor finger in the previously formed tunnel, wrapped around the main phalanx and sutured to itself in the palmar incision. If there is a skin defect on the hand, then the skin part of the flap replaces it. The vascular pedicle of the flap is brought to the site of the recipient vessels through an additional incision connecting the area of anastomosis and the palmar wound. Then impose anastomoses on the artery and veins of the flap and recipient vessels. The wound is sutured and drained. Immobilization is carried out with a plaster splint bandage for 3 weeks.

Second phase. Actually pollicization of the finger-donor in the position of the first finger. Stump preparation. Excised scars on the end of the stump, refresh it to prepare for osteosynthesis, mobilize the skin. Allocate the extensor tendons of the first finger, dorsal veins.

On the palmar surface, the digital nerves and the tendon of the long flexor of the first finger are mobilized.

Isolation of the donor finger on the vascular pedicle. Initially, on the palmar surface, before the tourniquet is applied, the course of the vascular pedicle is noted along the pulsation. A skin incision is made at the base of the donor finger with triangular flaps cut out on the back and palmar surface. Subcutaneous veins are isolated on the back surface of the finger, and after marking they are crossed. Cross the extensor tendon of the finger. An incision is made along the palmar surface from the top of the triangular flap along the marked vascular pedicle. Carefully allocate actually digital nerves. The disarticulation of the finger in the metacarpophalangeal joint is performed by dissecting the joint capsule and crossing the tendons of the short muscles. The finger is lifted on a new vascular pedicle by carefully separating it in the direction of the stump of the first finger.

Isolation of the vascular pedicle is continued until sufficient length of it is allocated for rotation without tension. At this stage, the tourniquet is removed and the blood supply to the finger is controlled. An incision along the palmar surface of the stump of the 1st ray is connected to an incision in the palm in the region of the isolated vascular pedicle.

The vascular pedicle is unfolded and placed in the incision.

Fixation of the donor finger in positionIfinger. Resection of the articular surface of the base of the main phalanx of the donor finger is performed. The finger is rotated 100-110° in the palmar direction in order to position the palmar surface of the donor finger in opposition to the remaining long fingers.

Osteosynthesis is performed with Kirschner wires, trying not to restrict movement in the interphalangeal joints of the transplanted finger. The extensor and flexor tendons are restored and the digital nerves proper are sutured epineurally. If there are signs of venous insufficiency under a microscope, anastomoses are applied to 1-2 veins of the donor finger and the veins of the dorsal surface of the stump of the first finger.

On the back surface of the stump, a skin incision is made to lay a triangular flap in order to avoid a circular compressive scar.

The wound is sutured and drained. Immobilization is carried out with a plaster splint bandage until consolidation occurs.

This section looks at each finger in turn, analyzing factors such as the length, width, signs, and phalanges of each finger individually. Each finger is associated with a specific planet, each of which, in turn, is associated with classical mythology. Each finger is seen as an expression of a different side of the human character. The phalanges are the length of the fingers between the joints. Each finger has three phalanges: main, middle and initial. Each phalanx is associated with a special astrological symbol and reveals certain personality traits.

The first, or index, finger. In the ancient Roman pantheon, Jupiter was the supreme deity and ruler of the world - the equivalent of the ancient Greek god Zeus. In full accordance with this, the finger bearing the name of this god is associated with ego, leadership abilities, ambition and status in the world.

The second, or middle, finger. Saturn is considered the father of Jupiter and corresponds to the ancient Greek god Kronos, the god of time. The finger of Saturn is associated with wisdom, a sense of responsibility, and a general attitude in life, such as whether a person is happy or not.

The third or ring finger. Apollo, god of the Sun and youth in ancient Roman mythology; in ancient Greece, it corresponded to a deity with the same name. Since the god Apollo is associated with music and poetry, the Apollo finger reflects a person's creativity and sense of well-being.

The fourth finger, or little finger. Mercury, among the Greeks, the god Hermes, the messenger of the gods, and this finger is the finger of sexual intercourse; it expresses how clear a person is, that is, whether he is really as honest as he says about it.

Definition of phalanges

Length. In order to determine the phalanx, the palmist considers factors such as its length compared to other phalanges and overall length. In general, the length of the phalanx reflects how self-expressive a person is in a particular area. Lack of length indicates a lack of intelligence.

Width. The width is also important. The width of the phalanx indicates how experienced and practical a person is in a given area. The wider the finger, the more actively the person uses the special features led by this phalanx.

marks

These are vertical lines. As a rule, these are good signs, as they channel the energy of the phalanx, but an excessive number of grooves can mean stress.

stripes are horizontal lines across the phalanx that have the opposite effect of the grooves: they are believed to block the energy released by the phalanx.