MINISTRY OF THE HIGHER AND SECONDARY VOCATIONAL EDUCATION REPUBLIC OF UZBEKISTAN
ZDAROVOOKHRANENIYE'S MINISTRY UZBEKISTAN TASHKENT MEDICAL ACADEMY
The vice rector on study
prof. Teshayev O. R. _________
«_____» _________ 2012.
Chair: Traumatology orthopedics, VGTH with neurosurgery.
Subject: Traumatology orthopedics.
For medico-preventive faculty
on a subject:
Basic principles of treatment of changes and dislocations of a shoulder, forearm and brush.
SRS: Ankiloza and contracture of joints.
Practical occupation No. 5
TECHNOLOGY OF TRAINING
TASHKENT-2012
Practical occupations No. 5
Subject: Basic principles of treatment of changes and dislocations of a shoulder, forearm and brush.
Ankiloza's SRS-and contracture of joints.
1. Subject and equipment venue
- chair: Traumatology orthopedics, VPH with neurosurgery;
- banners, X-ray pictures, distributing materials, photo and video material.
- new investment technological technologies,
2. Time of carrying out occupations
225 minutes (5академических hours)
3. Occupation purpose. To acquaint students about the basic principles of treatment of changes and
dislocations of a shoulder, a forearm and a brush, rendering of the first medical care, to inspection methods,
types of anesthesia, immobilization principles. To train students in skills of interpretation a X-ray of pictures,
local anesthesia of a place of a change.
4. Pedagogical tasks
- to fix general idea about fractures of a shoulder, a forearm and a brush.
- to fix general idea about dislocations of a shoulder, a forearm and a brush.
- to fix knowledge of an etiology of changes and dislocations;
- to deepen concepts about the basic principles of treatment of changes;
- to deepen concepts about the basic principles of treatment of dislocations;
- to expand knowledge of conservative methods of treatment of changes and dislocations;
- to fix and expand knowledge of practical skills.
5. Results of educational activity.
The student should know
- classification and types of fractures of a humeral bone, forearm and brush bones;
- the main clinical signs at fractures of a humeral bone, forearm and brush bones;
- principles of rendering of the first medical care;
- inspection methods, types of anesthesia and immobilization.
The student should be able:
To carry out practical skill - equipment of an immobilization Kramer's tire at injury of a humeral bone.
6. Methods and technicians of training
Case
7. Tutorials
- Traumatology orthopedics, VPH with neurosurgery;
- For carrying out practical skills: X-ray pictures, distributing materials, photo and video.
- New technological grants
8. Forms of education
Individual work, work in groups, collective.
9. Training conditions
The audience having conditions for work in groups.
10. Monitoring and assessment
- Oral control: control questions, performance on a subject test questions, organizers, interactive games.
- Performance of practical skills.
Technological card of educational occupation.
Content of activity
Work stage
teacher
The I stage
Introduction
educational
occupation
(10 mines)
Students
– 1.1. Calls an occupation subject, its purpose, tasks Listen
in and planned results of educational activity.
Write down
Independently
study
1.2. Acquaints with an operating mode on occupation contents of a case and
and criteria of an assessment of results (see individually fill a leaf of the
methodical instructions for students).
analysis of situations.
5 minutes
1.3. Explains appointment a case-stadi and its
influence on development of professional knowledge.
1.4. Раздаёт case materials also acquaints with a
situation analysis algorithm (see methodical
instructions for students).
1.5. Gives a task independently to carry out the
analysis and to bring results in «A leaf of the analysis
of a situation».
II stage
2.1. Carries out quiz on purpose to make active
knowledge being trained on a subject:
Answer questions
Make change definition?
Make dislocation definition?
You know what basic principles of treatment of a
change and dislocations?
You know what methods of a conservative method
of treatment of changes and dislocations?
List complications of a conservative method of
treatment of changes and dislocations?
2.2. Divides students into groups.
Reminds work rules in group and ruled discussions.
2.3. Gives a task:
To carry out and discuss results of individual work
with a case (sheets of the analysis of a situation) in
mini-groups;
To estimate and choose optimum options of actions
for a conservative method of treatment of changes
and dislocations;
Share on groups.
To be prepared for presentation.
Carry out an educational
task.
Change
2.4. Coordinates, advises, directs educational activity.
Checks and estimates results of individual work:
sheets of the analysis of a situation.
2.5. Will organize presentation following the results
of the done work on the solution of a case, discussion
and a vzaimootsenka.
Change
2.6. Makes comments, pays attention to the actions
chosen in the course of the analysis for a conservative
method of treatment of changes and dislocations.
2.7. Reports the version of the decision.
Groups hold presentation of
results of work. Participate in
discussion, ask questions,
estimate.
Main 30 minutes.
2.8. Will organize performance by students of Measurement of relative and
absolute length of the
practical skills
bottom extremity
Examination of patients
III stage final and 3.1. Sums up to occupation, generalizes results of Measurement of relative and
educational activity, declares estimates individual and absolute length of the
estimated
collaboration.
bottom extremity
10 minutes.
3.2. Emphasizes value a case-stadi and its influence
on development of future expert.
3.3 Gives homework.
11. Motivation
Carrying out this occupation gives the chance to the being trained the X-ray of pictures, local anesthesia a
place of a change, preparation of plaster bandages, imposings of langetny and circular plaster bandages,
delivery of the preliminary diagnosis and definition of further tactics of maintaining the patient will
familiarize with the basic principles of rendering of the first medical care, to inspection methods, types of
anesthesia, principles of an immobilization, interpretation.
12. Intersubject and intra subject communications
Training of students, on this this subject, is based on knowledge of human anatomy, topographical anatomy
and operative surgery, radiology, anesthesiology resuscitation and sheathe surgeries.
13. CONTENT OF OCCUPATION
Theoretical part:
Spiral changes of a diaphysis of a shoulder occur owing to rotational, and slanting and horizontal - owing to
angular tension. The shattered changes grow out of direct crushing action. At injury of a shoulder stay
отломков at each other as at changes of a diaphysis of a hip, a bolypebertsovy bone for muscles of the top
extremity are rather shorter and weaker, their reductions are limited to weight of an extremity is observed.
Nevertheless the muscular draft which is not meeting resistance, can cause some types of typical shifts. At a
change under a shoulder neck the proximal fragment is taken away by draft надостнои muscles as well as at
not wedged fractures of a neck of a shoulder. At a change below a place of an attachment of a big chest
muscle this strong muscle gives the top end pulls it кнутри and кпереди. If the change is even more low,
attachments of a deltoid muscle are lower, the tendency to assignment of a proximal fragment is again
found.
Such shifts are easily corrected, and good comparison can be reached by simple methods. In continuous
extension of need isn't present, as it is easily possible to get restretching and the slowed-down accretion of a
change. Very exact comparison isn't required. Small lateral shift has no essential value neither with cosmetic,
nor from the functional point of view.
Plaster лонгета and suspension on a kerchief
Spiral changes of a diaphysis of a shoulder grow together quickly and easily. Conditions so favor to accretion
that in 5-6 weeks, despite an insufficient immobilization, accretion indicators are clinically noted. It is
required to apply only a zhelobovaty shinka or a bandage with a collar and a cuff, or long plaster лонгету,
going of an axillary hollow down on shoulder inside round an elbow joint with transition to the outer side of
a shoulder. Longeta strong bandage in the specified situation and an extremity suspend on a kerchief.
Right after imposing of a bandage appoint movement of fingers and a beam - a carpal joint. It is shown even
through certain intervals to remove a kosynochny bandage for exercises of a humeral joint. In process of
hypostasis reduction plaster лонгету strengthen circular bandage that supports good comparison отломков
enough. In 5-6 weeks clinical indicators of accretion of a change are observed. In the absence of pains,
"pruzhinnost" in a change place a plaster bandage carefully
remove also movements in elbow and beam joints restore active exercises.
Plaster лонгета. Tire
At a cross-section change restoration occurs more slowly and big degree of an immobilization is required.
After imposing plaster лонгеты an extremity bandage to the taking-away tire immobilizing humeral and
elbow joints.
Kramer's wire taking-away tire
The special taking-away tire is very expensive, but the taking-away tire designed from the wire tire of Kramer
is quite satisfactory.
The plaster bandage with an immobilization of a humeral joint can be other method of treatment. Extent of
assignment and bending forward a shoulder depends on change level. As a rule, the best situation is
assignment on 60 ° and situation ahead of the face-to-face plane on 40 ° so that the hand of the patient was
always ahead of his chin.
In 6 weeks clinically define extent of accretion of a change. At rather complete accretion a plaster bandage
remove. If accretion more not enough, it is possible to continue an immobilization for 2-3 weeks. Full
mobility отломков is very seldom found. In similar cases the surgeon should be especially careful as the
further destiny of a change depends only on behavior of the attending physician.
Complete accretion is still possible, but if precautionary measures aren't accepted, possibility even bone not
accretions isn't excluded that further will demand kostnoplastichesky operation.
Changes of a diaphysis of a shoulder with the slowed-down accretion
The patient should be immediately warned about the extended terms of treatment. While the usual change
grows together in 5-6 weeks, accretion of such change can proceed 5-6 months and even more long.
All this time the immobilization should be full and continuous. Imposing лонгеты and a kosynochny bandage
or a bandage with a collar and a cuff can't be considered as quite reliable immobilization therefore it is better
to apply a plaster bandage with fixing of humeral and elbow joints. It is necessary persistently and to carry
out systematically exercises for fingers, but not for other joints. The immobilization should be spent a long
time while x-ray pictures won't give possibility to ascertain change consolidation.
Movements in elbow and humeral joints begin not earlier than complete accretion, differently the bone
callosity can be absorbed and the change won't grow together. Not accrete changes of a diaphysis of a
shoulder At the slowed-down accretion caused by an insufficient immobilization, the sclerosis of surfaces of a
change and operative treatment in the beginning is observed isn't shown. Only the full immobilization of a
change in a plaster bandage with fixing of a humeral joint is required. The immobilization should proceed
some months before complete consolidation of a change. According to other surgeons, at not accretion of a
change and a sclerosis of bone fragments operation of bone plasticity is recommended. It is necessary to
check an integrity of a beam nerve. At an exposure of a nerve it remove aside retraktor to an exposure of a
bone or transplant imposing. As the method of reliable fixing can be shown an intra bone shtiftovaniye with
an autoplasty. Paralysis of a beam nerve Changes of an average third of a diaphysis of a shoulder often
become complicated paralysis of a beam nerve owing to its contusion. Usually paralysis passes without
operative intervention. At long paralyses an extremity suspend, impose plaster лонгету on a forearm and a
brush, and the beam joint is in the provision of a dorsalny inflection, a pyastno-phalanx joint - almost in a full
razgibaniye, and interphalanx joints at all don't immobilize. If in 6-8 weeks there are no signs of restoration of
function of nerves at change accretion, the nerve exposure is necessary. It bare above and below level of a
change and make невролиз or nerve sewing together depending on an operational find. Forecast good.
Main questions of treatment of fractures of a humeral bone. A transport immobilization, anesthesia of area
of a change - blockade of a place of a change, the technician of its carrying out.
Two ways of reposition displaced bone pieces
1. The one-stage forced reposition: manual reposition, reposition by special devices.
2. Gradual (etapny) reposition by means of long extension.
Immobilizatsionny (fiksatsionny) method: indications to method application. The traumatologic characteristic
of a change according to V.A.Chernavsky:
Existence or absence of shift bone отломков, difficulty or comparative ease of reposition of bone fragments,
stability or instability of bone fragments after reposition. The changes having «the positive traumatologic
characteristic», the changes having «the negative traumatologic characteristic» an extremity.funktsiya after
change consolidation at not eliminated shift on length, at an angle, rotational and shift on width.
Equipment of an one-stage repozitsiya for the top extremity and for the bottom extremity, a plaster
immobilization. Plaster, its properties, preparation of plaster bandage and their storage, tools applied in
plaster equipment: plaster tables, devices applied when imposing plaster bandages. Types of plaster
bandages: lining and bezpodkladochny plaster bandages. Longetnye, longetno-circular, circular plaster
bandages, plaster tutor. Rassechennye and not rassechenny plaster bandages. Equipment of imposing of
plaster bandages, marking of plaster bandages. A X-ray control after imposing of plaster bandages. Rules of
care of plaster bandages - rules of transfer and a rule of laying of the patient and a sick extremity on a bed,
supervision over fingers of the injured extremity, emergence and strengthening of pains under a plaster
bandage, purity of a plaster bandage.
Complications at an immobilization a plaster bandage.
• Irritation of skin along the edges of plaster.
• Hypostasis of fingers of a hand or foot.
• Skin bubbles.
• Purulent dermatitis.
• Decubituses under plaster.
• Folkman's ischemic contracture.
New pedagogical techniques used on this occupation:
«Round table»
For work it is necessary:
1. A set of questions and the situational tasks which have been unpacked on single sheets.
2. Nomerki for lot on number of students in group.
3. Clean sheets of paper, handles.
Work course:
1. All students of group share lot on 3 groups on 4 students in everyone.
2. Each subgroup sits down at a separate table, prepares a clean sheet of paper and the handle.
3. On a leaf date, group number, faculty, First name, middle initial, last name students of participants of the
entitled group (business game) is written.
4. One of participants of each subgroup takes a question from an envelope. Level of complexity of questions
and tasks is approximately identical to all subgroups.
5. Students copy the task for a leaf.
6. Around start up this leaf.
7. Each student writes down the version of the answer and transfers a leaf to another.
8. On the answer of each student it is taken away for 3 minutes.
9. After operating time press to the teacher.
10. All participants discuss results, choose the most right answers for which are put the maximum point.
11. For discussion 15 minutes are taken away.
12. Students get for answers points from a rating of a theoretical part of occupation.
0,8-0,7 points «5»
0,6-0,4 «4»
0,4-0,1 «3»
0 2»
13. The point got by the student is considered at exposure of an assessment for
current occupation
14. In the lower free part of the magazine the mark about carrying out becomes
games with an inscription of the head of group.
15. Works of students remain the teacher.
1-situational task.
Sick in the L. 18 years, arrived with complaints on existence of pain and movement restriction in the right
elbow joint.
1. Your preliminary diagnosis.
2. Tactics of rendering of the first medical aid.
3. What methods of inspection are carried out?
4. VOP tactics.
2-situational task.
The patient of Page of 42 years, arrived with complaints on existence of pain and movement restriction in
the left humeral joint. From the anamnesis casually fell on the given extremity.
1. Your preliminary diagnosis.
2. Tactics of rendering of the first medical aid.
3. What methods of inspection are carried out?
4. VOP tactics.
3-situational task.
Patient And. 25 years, arrived samoteky in traumatologic point with complaints on pain existence in the left
forearm. From the anamnesis was traumatized during football. At survey deformation in the field of an
average third of a forearm, and also a swelling is noted.
1. Your preliminary diagnosis.
2. Tactics of rendering of the first medical aid.
3. What methods of inspection are carried out?
4. VOP tactics.
13.2. Analytical part
13.2.1. Situational tasks:
1-situational task
The sick M of 24 years, arrived with complaints on pain existence on right a shoulder. From the anamnesis
itself fell at home arm-distance. At survey the expressed hypostasis and deformation at level of an average
third of the right shoulder visible shortening of an extremity is noted. A pulsation on peripheral vessels the
accurate.
• Your preliminary diagnosis.
• Main methods of research.
• With what diseases it is necessary to make differential diagnostics.
• VOP tactics
2-situational task
Patient. 45 years, arrived with complaints on existence of pain, a swelling and on movement restrictions in
the left elbow joint. From the anamnesis was to bring down by car. At survey the smoothness and
deformation of the left elbow joint is noted, at a palpation the expressed morbidity in the field of an external
condyle of a humeral bone is noted, violation of a triangle of Günter is noted.
• Your preliminary diagnosis
• Main methods of research
• With what diseases it is necessary to make differential diagnostics
• VOP tactics
13.2.2 Practical part
Practical skill – an immobilization Kramer's tire at injury of a humeral bone.
Purpose: To master equipment of first-aid treatment at injury of a trifling bone.
Equipment: Volanter, couch, syringe, новокаин 0,5 %, Kramer's tire, bandage.
Carried-out stages (steps).
№
Stages
Actions
1.
Anesthesia by analgetics. (for the general anesthesia)
2.
Local anesthesia of novokainy 0,5 % (for fixing of the injured
extremity)
Okutavaniye vatno - a gauze bandage of the tire of Kramer
(for protection from irritation of skin)
Imposing of the tire of Kramer of pyastno-phalanx joints to a
humeral joint (for fixing)
Okutavaniya bandage (For stabilization)
3.
4.
5.
In total
14. Types of examination
- the oral;
it is not
executed (0
points)
0
Completely
it is correctly
executed
20
0
20
0
20
0
20
0
20
100
- the written;
- situational tasks;
- to show abilities of performance of practical skill.
15. Criteria of an assessment of the current control on a subject: «Basic principles of treatment of changes
and dislocations of a shoulder, forearm and brush»
№
Progress in %
Assessment
Level of knowledge of the student
1
96-100%
It's cool
Depending on a situation can make the correct decision
and sums up.
2
91-95%
“5”
By preparation for a practical training uses additional
literature (as on native, and in English) Independently
analyzes essence of a problem at inspection of patients
with damages and diseases the ODE. Can independently
examine the patient and correctly makes the diagnosis.
Shows high activity, a creative approach at carrying out
interactive games. Correctly solves situational problems
with complete justification of the answer. During SRS
discussion actively asks questions, does additions.
Practical skill carries out surely, understands essence
3
86- 90%
It's cool
By preparation for a practical training uses additional
literature (as on native, and in English)
4
76-80%
“5”
Shows high activity at carrying out interactive games.
Correctly solves situational problems, but can't appoint
concrete treatment, confuses dosages of preparations.
Knows AFO of bone and muscular system, tells surely. Has
exact representations on an etiology, патогенезу, to
clinic, can carry out differential diagnostics, to appoint
treatment, but can't carry out traumatism prevention.
5
71-75%
It's cool
Practical skill carries out on steps.
6
66-70%
“5”
Correctly collects the anamnesis, examines the patient,
makes the preliminary diagnosis. Can interpret these
laboratory researches. Actively participates in SRS
discussion.
7
61-65%
Well
Commits mistakes at the solution of situational tasks
(can't expose the diagnosis on classification). Knows clinic
at inspection of patients with damages and diseases the
ODE, tells not surely. The ODE and a traumatism has
exact representations on an etiology damage and a
disease, but can't connect clinic with the patogenezy.
Collecting the anamnesis not purposeful, survey not
according to the scheme. Can't interpret data of
laboratory researches. It is passive at SRS discussion.
8
9
10
55-60%
“4”
Has the general representations about treatment
methods in traumatology and orthopedics, tells not
surely. Confuses AFO of bone and muscular system. Can't
independently interrogate and examine the patient. Can't
interpret data of laboratory researches. Doesn't
participate in SRS discussion
30-54%
Well
The ODE has no exact representation of the basic
principles inspection of patients with damages and
diseases.
20-30%
“4”
Doesn't know AFO of bone and muscular system.
SRS: Ankiloses and contracture of joints
Questions for check:
1. Classification of contractures
2. Etiopatogenez and clinical current анкилоз and contractures of joints
3. Prevention of contractures
17 Control questions
1. Classification and types of fractures of a humeral bone?
2. Mechanism of injury of a humeral bone?
3. Basic principles of treatment of a fracture of a humeral bone?
4. Main types of plaster bandages?
5. Clinic of a change of Montedzha?
6. Clinic of a change of Galeatsiya?
7. Rational choice of a method of treatment of changes.
8. Clinic of a change of Bennet?
18 Recommended literature
1. Yumashev G. S. «Traumatology and orthopedics of» M «, Medicine» 1990. - 575с.
2. Musalatov H.A. «Traumatology and orthopedics of» M «, Medicine» 1995. - page.
3. A. V.Kaplan «Injuries of bones and joints» Moscow «Medicine> 1979. - 568с.
WWW.ejbjs.org WWW.jbjs org.uk WWW.traumatic.ru WWW.trauma.bd.ru