MINISTRY OF THE HIGH AND MIDDLE EDUCATION OF THE REPUBLIC
OF UZBEKISTAN
MINISTRY OF HEALTH OF THE REPUBLIC OF UZBEKISTAN
TASHKENT MEDICAL ACADEMY
«Approved» by vice
rector on academic affairs
prof. Teshayev O. R.
«_____» _________ 2013.
Chair: Traumatology orthopedics, MFS with neurosurgery.
Subject: Traumatology and orthopedics.
For medicol-prophylactic faculty
Subject: «Surgical methods of treatment in traumatology and orthopedics.
Reparative regeneration of a bone fabric»
SWS – Feature of fractures of bones at children.
United methodical system
Practical occupation № 3
TASHKENT-2013
Originators:
Head of the Traumatology - orthopedics, MFS with neurosurgery
cathedra: MD Karimov. M Yu.
manager of a teaching department: Salokhiddinov. F.B.
The technology of training is approved:
Azizova F.H. prof – chief of studying department of the TMA.
Discussed and recommended to approving
Head of the cycle subject section of medico-prophylactic faculty
Professor: B.M. Mamatkulov
Practical occupation No. 3
Educational model in studying process
On a subject: Surgical methods of treatment in traumatology and orthopedics. Reparative
regeneration of a bone fabric.
SWS -of Feature of fractures of bones at children.
Technology of studying lesson
Time: 225 min
Form and type of studying
lesson
Structure of Practical lesson
Aim of studying lesson:
Student should know:
Students: 10-12
Practical lesson
1. Introduction.
2. Theoretical part.
3. Analytic part.
- Case-study
- Tests and task
4. Practical part.
To form of skills and to improve knowledge of students in feature patient’s
examination with damages of the musculoskeletal system. To teach
interpretation of X-ray, prepare and set of splinting.
- know, how to find anterior superior crista of iliac bone
- know, how to measure
- to find relative length
- to find absolute length
- to find length of the hip and shin
Student should know:
To make practical skills: to teach anthropometric methods exam
traumatlogical patient.
Obligations of teachers:
To introduce, characterize,
explain and teach
anthropometric methods exam
traumatlogical patient.
Methods and technique of
studying
Form of studying lesson
Material of studying
Condition of studying
Results of studying activity:
To count anthropometric methods:
Giving expand characteristics to each methods;
Name in steps anthropometric methods;
To make up, determine and plan methods investigation of traumatlogical
patient.
Case, interactive games, lection
Individual work, group work, collective work.
- Handbook, movies, photos, books.
- Studying materials, X-rays, studying movies, tourniquet, splint
material.
Auditoria for work with group.
Monitoring and assessment:
- Oral control: control questions, carry out tasks in group.
Writing control: control questions, to find relative and absolute length of
lower extremity
Flow chart of educational classes on surgical treatment in traumatology and orthopedics.
Reparative regeneration of bone tissue.
Work stage
Contain of activity
Teacher
Students
1.1. Calls an occupation subject, its Listen
purpose, tasks and planned results of
The I stage –
Write down
educational activity.
Introduction in
Independently
study
educational
contents of a case and
occupation
1.2. Acquaints with an operating mode on individually fill a leaf
(10 mines)
occupation and criteria of an assessment of of the analysis of
results (see methodical instructions for situations.
students).
5 minutes
1.3. Explains appointment a case-study
and its influence on development of
professional knowledge.
1.4. case study 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
Answer questions.
subject:
- features of inspection of patients with
diseases the ODE;
- features of inspection of patients with
damages the ODE;
- concept about diagnostics of injury of
bones;
- concept about diagnostics of injury of
joints;
- idea of a traumatism on production;
- measures of prevention of a traumatism
on production;
2.2. Divides students into groups.
Reminds work rules in group and ruled
discussions.
Share on groups.
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
out
options of actions for measures of Carry
prevention of a traumatism on production; educational task.
To be prepared for presentation.
Change
2.4.
Coordinates,
educational activity.
advises,
directs
Checks and estimates results of individual
an
work: sheets of the analysis of a situation.
2.4.
Coordinates,
educational activity.
advises,
directs
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
assessment.
Groups
hold
presentation of results
of work. Participate in
discussion,
ask
2.6. Makes comments, pays attention to
questions, estimate.
the actions chosen in the course of the
analysis for measures of prevention of a
traumatism on production.
Change
2.7. Reports the version of the decision.
Main 30
minutes.
2.8. Will organize performance
students of practical skills
by Measurement
of
relative and absolute
length of the bottom
extremity
Physical examination of patients
III stage final 3.1. Sums up to occupation, generalizes Listen
and estimated
results of educational activity, declares,
estimates individual and collaboration.
10 minutes.
3.2. Emphasizes value a case stage and its
influence on development of future expert.
Express the opinion
3.3 Gives homework.
Write down
1. INTRODUCTION
1.1 PLACE OF LESSONS
1.3. between and intra subject relations: teach this theme is based at
student’s knowledge by anatomy, topographic anatomy, radiology,
surgery and reanimation.
2. theoretical part.
2. 1. The osteosynthesis is a surgical connection bone fragments in the various
ways.
Osteotomiya operative section (crossing) of a bone.
Transplantation of a bone is the change of the various bone fabrics applied to
filling of formed defects in bones (after removal of good-quality tumors).
Joint operations are subdivided into two groups:
1. Interventions on soft fabrics of a joint: an arthrotomy – joint opening, a
synovectomy – an remove of an articulate bag, plastic of the copular device.
2. Operation on the bones forming a joint.
Joint resection – a remove of the articulate ends of the bones struck with any
pathological process.
Arthroplastics – mobility restoration in a joint.
Arthrodesis – artificial creation of an immovability of a joint.
Big distribution was received by methods KDA, Kalnberz's osteosyntheses
\devices.
Phases of a cycle of restoration of a bone:
The first phase – the beginning of development of a reproduction and a
proliferative of cellular elements under the influence of products of a necrosis
damaged cages and fabrics. Major importance in formation of a bone callosity has
blood circulation restoration in the field of a change.
The second phase – education and a differentiation of fabric structures. It is
characterized by a progressing proliferative and a differentiation of cellular
elements that occurs thanks to anabolic hormones. Young bone cages form an
organic basis bone. Under optimum conditions the fabric is formed.
The third phase – formation of bone structure. The main process is the complete
recovery of blood circulation in a place of a change and a mineralization of an
albuminous basis. The space between fragments bones is filled with a cellular
network bone from a coarse-fibered and lamellar bone fabric. By the phase end
bone merge in compact substance with wide bone channels.
The fourth phase – reorganization primary and a bone restitution. In this stage the
accurate layer is defined, the marrowy channel is restored, the accurately
differentiated. The chaotic arrangement of structures is replaced by their
orientation, a superfluous .
General regularities of reparative bone regeneration
Reparative regeneration of a bone fabric — formation of a bone fabric on a place
of injury of the bone, directed on its high-grade structural restoration.
Feature of bone reparative regeneration — its current at which each subsequent
stage happens a consequence previous. From the moment of injury of a bone
before reparation end, i.e. formation of a morph of logically mature bone fabric
filling defect and connecting bone fragments, and achievements of high-grade
restoration of functions of a bone as itself body there passes a lot of time. Thus the
general regularities of a course of reparative process of a bone fabric and the
specific features depending on conditions of its current, potentialities of
osteogenetic cellular elements, and also from a condition of all organism are
distinctly traced. The general regularities of reparative process in the injured bone
and its end, occurring in optimum conditions, are presented in a look different
"generalized character". Optimum conditions mean a simple closed fracture of a
long tubular bone, the correct reduction and good fixing bone fragments.
The damage stage, or primary destruction, usually happens mine, but its
extensiveness depends on an injuring factor (in the case under consideration mechanical character): its forces, duration and areas step game. At most often met
closed fracture of a long tubular bone there is a violation of its integrity to division
into two bone (distal and proximal). Are thus broken off , a bone fabric and all
elements, in them present and with them connected: fibrous (collagenic and elastic)
and cellular (osteocytes, cages predecessors) elements, a marrow, blood and
lymphatic vessels, nerves, the fabrics surrounding a bone.
Thus, the trauma causes a destruction of fabric elements in the field of damage,
violation of interrelation of the remained fabric elements and change of fabric
spatial very tectonics. It follow chemical and biochemical changes of the
environment in a damage zone, I initiate new (other) structural changes.
Stage of consequences of primary destruction, secondary destruction. As a result of
alteration in the center of damage the develops inflammatory. Its first sign — the
blood-groove and frustration connected with a vazodilatation and being
accompanied by increase of permeability of a vascular wall therefore there is an
exsudation, i.e. an exit from vessels in a fabric of water, proteins, salts and blood
cells. Thereof arises swelled surrounding fabrics. In the center of an inflammation
find metabolism products, toxins. It is followed i.e. by migration of leukocytes and
them to it, surrounding the inflammation center. The inflammatory rheological
properties of blood develops, there are, local hemorrhages, thrombosis of small
vessels, a exudate. As a result of a metabolic disorder in the center of an
inflammation acidosis, a hypoxemia and hyper osmium develop. In reaction in the
center there is a large amount of enzymes that causes disintegration of the damaged
fabrics. Between bones develops blood clot. At a change of a cortical part of a
diaphysis there is a rupture of the vessels passing in the central channels that brings
to blood-groove dyeing on them on some depth from damage border to a place of
their next branching or vessels adjacent. 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 splint 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.
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.
To congenital defects of development of the musculoskeletal device, meeting at
children of early and preschool age, the congenital clubfoot, congenital dislocation
of a hip and a congenital muscular wryneck belong. The congenital clubfoot — is a
contracture of joints of foot. The disease meets at boys more often, the clubfoot
happens one - and bilateral. The main clinical signs of a congenital internal
clubfoot are: plantar bending of foot in an ankle joint, turn of a plantar surface
inwards with lowering of external edge of foot, mainly tarsi and metatarsuses, foot
reduction in forward department at simultaneous increase in the arch of foot —
hollow foot. Congenital clubfoot treatment consists in special correlation
gymnastics, bandaging which needs to be begun on the first month of life of the
kid and at an easy form of deformation leads to an absolute recovery. Certainly,
massage – very effective means is necessary. At averages and heavy forms of an
illness plaster bandages are applied. If treatment begins after 2х years, it demands
operation before which to the child carry out treatment in the form of stage plaster
bandages.
Congenital dislocation of a hip - most frequent of congenital deformations of the
musculoskeletal device. When speak about frequency of this pathology, mean not
only the created dislocation of a femur which is seldom observed in the first days
of life, and a so-called displasy (the wrong arrangement of a head of a femur)
against which dislocation subsequently can be formed. At children of early age
meets two-and unilateral dislocation, and at girls more often than at boys. The
outcome depends on timely diagnosing of an illness and an initiation of treatment.
The diagnosis of a displasy of hip joints put in maternity hospital, with the same
purpose in children's policlinic of all babies (till 3 months) the surgeon-orthopedist
examines. The most frequent symptoms of a congenital displasy of a hip joint is
the following: assignment restriction in hip joints; click; asymmetry of folds on a
hip and buttock folds behind; shortening of the bottom extremity measured by eye.
The listed symptoms can be observed either at the same time everything, or only a
part, in the latter case it is necessary to suspect a congenital displasy of a hip joint
and to make a X-ray. If at the baby the diagnosis of a displasy isn't established,
when it starts to stand and go, diagnostics of congenital dislocation of a hip comes
easy. At children after a year one of characteristic symptoms is the late beginning
of walking: the first steps in 14 — 15 months, and also typical gait — is noted
instability, lameness — at unilateral dislocation, duck, rolling-over gait at bilateral
dislocation. Treatment of a displasy of hip joints is necessary for beginning at once
after diagnosis establishment on which term the way of treatment depends also.
Treatment can be conservative and operative and if the diagnosis is established on
the first year of life, conservative treatment is always applied. Congenital muscular
wryneck: A wryneck — the neck deformation, being characterized the wrong
position of the head (an inclination sideways and its turn). There is a wryneck
owing to pathological changes in soft fabrics, mainly in SCM muscle. The
specified deformation is more often happens right-hand and meets at girls. There is
also a bilateral wryneck. The congenital wryneck can be diagnosed on 2 — the 3rd
week of life of the child. On the struck party as a result of changes SCM muscle
there is a swelling of a dense consistence), not soldered to subject soft fabrics. At
the same time with the advent of dense there is a ducking towards the changed
muscle, but the head to the opposite side is turned. It the same position of the head
at such child — turn aside speaks. Treatment of a muscular wryneck should be
begun at once as soon as the diagnosis is established. It consists in the basic in the
gymnastic exercises which are carried out 3 — 4 times a day for 5 — 10 minutes.
Thus the head of the child lying on a back, clasp both hands and give it whenever
possible the correct situation, i.e. incline aside, opposite to the struck muscle, and
turn in the healthy. At the same time carry out massage healthy SCM muscle and
also a course of physiotherapeutic procedures. It is necessary to put a bed of the
newborn so that the child, watching the events in a room, could turn a head
towards the changed muscle, involuntarily giving it the correct situation. At
unsharply expressed form of a muscular wryneck timely and systematic
conservative treatment leads to complete treatment on the first year of life. At
heavier extent of deformation treatment proceeds till 3 years. In case of
unsuccessful conservative treatment operative intervention is shown to children
after 3 years. 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 splint 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.
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. To congenital defects of development of the
musculoskeletal device, meeting at children of early and preschool age, the
congenital clubfoot, congenital dislocation of a hip and a congenital muscular
wryneck belong. The congenital clubfoot — is a contracture of joints of foot. The
disease meets at boys more often, the clubfoot happens one - and bilateral. The
main clinical signs of a congenital internal clubfoot are: plantar bending of foot in
an ankle joint, turn of a plantar surface inwards with lowering of external edge of
foot, mainly tarsi and metatarsuses, foot reduction in forward department at
simultaneous increase in the arch of foot — hollow foot. Congenital clubfoot
treatment consists in special correlation gymnastics, bandaging which needs to be
begun on the first month of life of the kid and at an easy form of deformation leads
to an absolute recovery. Certainly, massage – very effective means is necessary. At
averages and heavy forms of an illness plaster bandages are applied. If treatment
begins after 2х years, it demands operation before which to the child carry out
treatment in the form of stage plaster bandages.
Congenital dislocation of a hip - most frequent of congenital deformations of the
musculoskeletal device. When speak about frequency of this pathology, mean not
only the created dislocation of a femur which is seldom observed in the first days
of life, and a so-called displasy (the wrong arrangement of a head of a femur)
against which dislocation subsequently can be formed. At children of early age
meets two-and unilateral dislocation, and at girls more often than at boys. The
outcome depends on timely diagnosing of an illness and an initiation of treatment.
The diagnosis of a displasy of hip joints put in maternity hospital, with the same
purpose in children's policlinic of all babies (till 3 months) the surgeon-orthopedist
examines. The most frequent symptoms of a congenital displasy of a hip joint is
the following: assignment restriction in hip joints; click; asymmetry of folds on a
hip and buttock folds behind; shortening of the bottom extremity measured by eye.
The listed symptoms can be observed either at the same time everything, or only a
part, in the latter case it is necessary to suspect a congenital displasy of a hip joint
and to make a X-ray. If at the baby the diagnosis of a displasy isn't established,
when it starts to stand and go, diagnostics of congenital dislocation of a hip comes
easy. At children after a year one of characteristic symptoms is the late beginning
of walking: the first steps in 14 — 15 months, and also typical gait — is noted
instability, lameness — at unilateral dislocation, duck, rolling-over gait at bilateral
dislocation. Treatment of a displasy of hip joints is necessary for beginning at once
after diagnosis establishment on which term the way of treatment depends also.
Treatment can be conservative and operative and if the diagnosis is established on
the first year of life, conservative treatment is always applied.
Congenital muscular wryneck: A wryneck — the neck deformation, being
characterized the wrong position of the head (an inclination sideways and its turn).
There is a wryneck owing to pathological changes in soft fabrics, mainly in SCM
muscle. The specified deformation is more often happens right-hand and meets at
girls. There is also a bilateral wryneck. The congenital wryneck can be diagnosed
on 2 — the 3rd week of life of the child. On the struck party as a result of changes
SCM muscle there is a swelling of a dense consistence), not soldered to subject
soft fabrics. At the same time with the advent of dense there is a ducking towards
the changed muscle, but the head to the opposite side is turned.
It the same position of the head at such child — turn aside speaks. Treatment of a
muscular wryneck should be begun at once as soon as the diagnosis is established.
It consists in the basic in the gymnastic exercises which are carried out 3 — 4
times a day for 5 — 10 minutes. Thus the head of the child lying on a back, clasp
both hands and give it whenever possible the correct situation, i.e. incline aside,
opposite to the struck muscle, and turn in the healthy. At the same time carry out
massage healthy SCM muscle and also a course of physiotherapeutic procedures. It
is necessary to put a bed of the newborn so that the child, watching the events in a
room, could turn a head towards the changed muscle, involuntarily giving it the
correct situation. At unsharply expressed form of a muscular wryneck timely and
systematic conservative treatment leads to complete treatment on the first year of
life. At heavier extent of deformation treatment proceeds till 3 years. In case of
unsuccessful conservative treatment operative intervention is shown to children
after 3 years.
Reparative regeneration of bone tissue
Bone regeneration may be physiological and reparative. Physiological regeneration is rebuilding
bone, during which there is a partial or complete resorption of the bone structures and creating
new ones. Reparative (replacement) regeneration is observed in bone fractures. This type of
regeneration is true, as the image of the normal bone. Restore the integrity of damaged bone cell
proliferation occurs through the cambial layer of the periosteum (periosteum), endosteum, poorly
differentiated pluripotent bone marrow stromal cells, and as a result of poorly differentiated
mesenchymal cell metaplasia paraossal tissues. The latter type of reparative regeneration of bone
tissue most actively manifests through mesenchymal cells growing into the adventitia of the
blood vessels. According to modern concepts, osteogenic precursor cells are osteoblasts,
fibroblasts, osteocytes, paratsity, histiocytes, lymphoid, adipose, and endothelial cells, the cells
of the myeloid and erythrocytic series. In histology called osteogenesis, the on-site fibrous
desmal connective tissue, in place of hyaline cartilage - enchondral, in clusters of proliferating
cells skeleton tissue - bone formation by mesenchymal type. Damage to the bone accompanied
by general and local changes after injury, through neurohormonal mechanisms in the body
include adaptive and compensatory system for matching homeostasis and repair damaged bone.
Formed in the fracture breakdown products of proteins and other components of the cells are one
of the triggers of reparative regeneration. Of cellular debris are the most important chemicals that
provide structural and plastic biosynthesis of proteins. In recent years, proved (AA Korzh, AM
Bilous, E. J. Pankow), which are substances such inducers nucleic nature (ribonucleic acid),
which affect the differentiation and the production of proteins in the cell.
In the mechanism of reparative regeneration of bone tissue are the following steps:
1) catabolism of tissue structures, dedifferensation and proliferation of cellular elements;
2) formation of blood vessels;
3) the formation and differentiation of tissue structures;
4) mineralization and alteration of the primary regenerate and restitution of bone.
Depending on the accuracy of matching fragments of bones, reliable and permanent immobilize
them, while maintaining the source of regeneration and other things being equal, there is a
difference in the vascularization of bone tissue. Emit (TP Vinogradov, GN Lavrishcheva, VI
Stenula, EY Dubrov) 3 types of reparative regeneration of bone tissue: the type of the primary,
primary and secondary delayed union of bone fragments. Fusion of the primary type of bone
occurs in the presence of a small diastasis (50 - 100 mm) and complete immobilization of
mapped fragments of bones. Fusion fragments occur in the early stages through direct bone
formation in the area of intermediate. In parts of the diaphyseal bone fragments on the wound
surface is formed skeletogennaya tissue that produces bone beams, which results in the primary
bone fusion with a small volume of the regenerate. In the regenerate bone at the junction of all
education is not marked cartilage and connective tissue. This kind of fusion of bones, with
minimal periosteal callus formation, where the compound fragments occurs directly through
bone trabeculae, is the most perfect. This type of fusion may occur in fractures without
displacement of bone fragments, a periosteal fractures in children, the use of strong domestic and
transosseous compression osteosynthesis. Primary-delayed type of fusion occurs in the absence
of the gap between the fixed firmly fixed bone fragments and is characterized by early, but only
partial fusion in the field of vascular channels with intracanal osteogenesis. Complete fusion of
intermediate fragments resorption precedes them all. In secondary type of union, when due to
poor matching and fixation of bone fragments have mobility between them and the trauma of the
newly regenerated, callus is formed mainly by the periosteum, and passing desmal introchondral
stage. Periosteal callus immobilize fragments, and only then is fusion directly between them. The
degree of fixation of bone fragments is determined by the value of biasing efforts and preventing
this offset (VI Stetsula). If the selected method fragments fixation of bone fragments provide a
complete comparison, recovery of the longitudinal axis of the bone, and the predominance of
force to prevent their displacement, the commit is reliable. To save in the period of union stood
motionless at the junction fragments should be used means of fixation, allowing to create a
significant excess of the value of the stability of bone fragments shift the effort. Stability margin
fragments allows early start function is active and the load on the limb. Compression of the bone
fragments together (compression) is not directly stimulates reparative regeneration and increases
the degree of immobilization than facilitates more rapid formation of callus. Depending on the
degree of compression of the bone fragments, according to the VI Stetsuly, reparative bone
regeneration proceeds differently. Weak compression (45 - 90 N/cm2) does not provide
sufficient stiffness of bone fragments, fusion of bone fragments and terms of its approach to the
secondary type. Create great compression (250 - 450 N/cm2) reduces the gap between the bone
fragments and resorption of all, slow down the formation of callus between. In this case the
recovery proceeding by seam. Optimal conditions for reparative regeneration of bone tissue
created by compression of medium size (100 - 200 N/cm2). The recovery process after a bone
injury is determined by several factors. Fusion of bones in children is more rapid than in adults.
Are important anatomical conditions (presence of the periosteum, the nature of the blood
supply), and the type of fracture. Oblique and helical fractures coalesce faster than transverse.
Favorable environment for bone fusion created when impacted and subperiosteal fractures. Level
of reparative regeneration of bone tissue is largely determined by the degree of trauma to tissues
in the fracture: the more damaged sources of bone formation, the slower is the process of the
formation of callus. Given this circumstance, in the treatment of fractures should be given to
methods not related to the application of additional injury to the fracture, and surgery should not
be traumatic. In the formation of callus is of great importance and respect to mechanical factors:
accurate mapping, create a contact, and reliable immobilization of bone fragments. The
osteosynthesis of the main condition for bone fusion is immobility fragments. For external
transosseous osteosynthesis by compression and fixation of bone fragments during the spokes
fixed in the machine, at the junction fragments are stiffness and optimal conditions for the
formation of primary bone union. At the junction of the bone fragments forming seam starts as
endosteal bone fusion, periosteal reaction appears much later. Accurate reduction and stable
fixation of bone fragments machine create the conditions for payment of intraosseous and local
blood flow, and helps to normalize the load early trophism. Distraction at the beginning there are
conditions for the formation of bone regeneration between slowly stretches the fragments, and
then formed at the junction coossification regenerates (VI Stetsula). Found that when there is a
distraction local osteoporosis with compression is not observed. Immobilization of bone
fragments is achieved rigidity machine, and tension fabric, binding fragments, and muscle
sheaths. In these conditions, the stability margin of fragments increases to the extent needed to
create a permanent and complete immobility "secondary" ossification of the regenerate. When
distraction conditions of formation between fragments of secondary bone union created by the
direct immobilization of bone fragments and "reparative osteogenesis." In meta- epiphisal
departments bone with good blood supply, with a firm compression osteosynthesis in the short
term is the joint in the entire area of contact between the fragments. When diaphyseal fractures
reparative reaction begins at a distance from the fracture site, and the site of the fracture appears
to restore blood flow. Initially formed endosteal, and then, later, periosteal adhesions. Fusion of
intermediate formed after the restoration of blood flow and increase vascular channels at the
ends of the fragments, in which the formation of new osteons (VI Stetsula). In oblique and
helical diaphyseal fractures with well-mapped fragments, when continuity is preserved bone
marrow and intraosseous vessels directly into the fracture is formed by rapid bone fusion.
Distraction at the optimum conditions for reparative regeneration of bone tissue are in still and
slow distraction of bone fragments. If these conditions diastasis filled fibrous connective tissue,
gradually turning into fibrous tissue, and in severe mobility fragments also formed cartilage and
formed a false joint. When dosed distraction of bone fragments and immobility diastasis between
the bone ends is filled with low-grade skeletogennoy cloth produced in bone marrow stromal cell
proliferation. Neoplasm of bone trabeculae appear in both fragments, continues through the
period of distraction on the tops of the regenerate bone connected by collagen fibers. With the
increase of diastase and maturation of both parts of the regenerate bone neoplasms process
continues on the border with the connective layer by deposition of bone density at the surface of
bundles of collagen fibers (desmalnaya ossification). Increasing the size of the regenerate during
its elongation is due to new formations of collagen fibers in the most connective gap; connective
layer in distraction regenerate the function of "growth areas" (VI Stetsula). After the cessation of
distraction, while maintaining stiffness of bone fragments, fibrous layer at the interface exposed
by bone regeneration desmalnoy replacement bone ossification and subsequent organ
reconstruction. In the treatment of organ reconstruction of bone tissue and promotes
mineralization dosed load on the limb. In the absence of immobility fragments process of
ossification of the connective layer dramatically delayed and at its border with the bony part of
the regenerate formed trailing plate. In severe immobility of fragments occurs partial resorption
of bone regenerates all with replacement by fibrous tissue, may form a false joint.
When extending the various segments of the limbs, and at different levels of the process of
formation of the regenerate osteotomy and restructuring its flow the same way. However,
depending on the level crossing bone distraction does not begin immediately after the operation,
but only after the connection of bone fragments of the newly formed connective tissue. The
intervention at the level of the metaphysis its start after the surgery in 5 - 7 days, and the shaft in 10-14 days. With the help of a gradual separation was possible at the level of the growth zone
epiphysis and metaphyseal bone. This way of lengthening bones called distraction
epiphysiolysis.
In distraction regenerate epiphysiolysis formation proceeds differently. The larger the area of
bone coming off the growth zone at osteoepifizeolize, the more proceeds reparative regeneration
of bone tissue. When the plate comes off a small amount of growth in bone diastasis mostly
filled regenerate, formed from the metaphysis. Formation of bone regeneration in place is also
lengthening of the periosteum and epiphysis. Level of reparative regeneration of bone tissue
depends on the degree of trauma to tissues in the fracture: the more damaged sources of bone
formation, the slower is the process of the formation of callus. Therefore, the treatment of
patients with fractures of the preferred methods of non-application of the additional trauma ¬
tion.
During the formation of callus is important to observe mechanical factors: accurate comparison,
creating contact and reliable immobilization of bone fragments.
Under present conditions it is possible to improve the conditions of reparative regeneration of
bone tissue. For these purposes, use anabolic steroids, the electromagnetic field, some drugs.
Anabolic steroids (retabolil) affect the processes of protein metabolism, promote the synthesis of
protein in the body prevent the development of post-traumatic catabolic processes and can have a
positive impact on the process of reparative regeneration of bone tissue. This influence is
particularly evident when the reparative processes are, for various reasons, are inhibited.
Retabolil intramuscularly 1 ampoule 3 times at 10-day intervals.
The electromagnetic field created by artificial means: the former is dipped into the bone tissue
regeneration special electrodes and connect to an external power source, the other - with the help
of magnets. The latter part of the limb, subject to exposure, is placed in the area of the
electromagnetic field. The effect depends on many factors: the power of the electromagnetic
field, frequency, and duration. Has a value and the period of reparative bone regeneration. This
problem is under intense scientific study. Found that, depending on the parameters of the
electromagnetic field generated can improve bone or inhibit this process.
2.2. NEW EDUCATIONAL TECHNOLOGY
Methodical recommendations games
GAME
"Swarm"
To work needed:
1. A set of setting and situational problems, printed on separate sheets.
2. Number plates for the draw in the number of students in each subgroup.
3. Blank sheets of paper, pen.
Progress:
1. All subgroups of students together to discuss the job. Total time - 45 minutes.
2. All the students are divided into groups by lot three subgroups on 4 students each.
3. Each subgroup sits at a separate table, preparing the paper and pen.
4. Written on a sheet date, the group number, department, name, participating students in this
subgroup and the name of the business game.
5. One student from each group takes the envelope of setting that is used for all subgroups.
6. One of the students in each subgroup rewrites on the job list.
7. They recorded his decision.
8. The decision set to 15 minutes.
9. The teacher watches the progress of the game.
10. After the time of the surrender teacher.
11. All the players discuss the results, select the most
right decisions for which is the maximum score.
12.Na discussion to 15 minutes.
13.Studenty get for answers from a rating of theoretical hours
classes.
14.Podgruppa, which gave the most correct answers will receive
maximum score of 100% of the theoretical part of the rating classes.
15.Na answer sheet scores and teacher puts his signature.
16.Poluchenny students score counted in the scoring
current occupation.
17. IN lower empty part of the magazine is on the mark
game warden signature group.
18. Work with students remain a teacher.
case studies 1
Do you have a reception Patient L. 72. Complains of pain in the right hip joint, the inability to
raise the limb. Anamnesis: 2 hours before entering the house fell from the chair on the right side.
On examination, marked external rotation of right leg, a symptom of "sticky heels." Active
flexion of the hip joint is not possible, passive painful. Skin sensitivity limbs and pulsation in the
peripheral arteries preserved.
• Your initial diagnosis
• What kind of help you prove?
• What additional methods you spend?
• Types of fixation in this condition?
case studies 2
Do you have a reception Patient A. 22. Complains of pain, swelling in the right knee joint,
increased pain during movement. Anamnesis: 20-30 minutes prior to receipt fell at the bus stop.
On examination, there is an increase of the circumference of the right knee joint in relation to
health. Palpation is determined kripitatsiya. Skin sensitivity limbs and pulsation in the peripheral
arteries preserved.
• Your initial diagnosis
• What kind of help you prove?
• What additional methods you spend?
• Types of fixation in this condition?
case studies 3
Do you have a patient on admission D 34. Complains of pain aggravated by movement and
swelling in the right thigh. Anamnesis: 30 minutes before admission fell from the bike. On
examination, there is an increase of the circumference of the right thigh in relation to healthy hip.
Palpation is determined by severe pain. The sensitivity of the skin and limbs ripple on peripheral
arteries preserved.
• Your initial diagnosis
• What kind of help you prove?
• What additional methods you spend?
• Types of fixation in this condition?
Criterion of assessment:
Max point 20-17,2
Excellent
100%-86%
17-14,2 ball
Good
85%-71%
14-11 ball
10,8-7,4 ball
7,2 ball
Satisfactory Unsatisfactory
Bad
70-55%
54%-37%
36% and below
2.3. Test questions for samopodgatovki:
1. Types of surgery.
2. Methods of osteosynthesis.
3.Oslozhneniya in surgical treatment.
4. Indications for surgical treatment.
5. Contraindications to surgical treatment.
6. Kinds of metal.
7. Stage of reparative regeneration?
8. Optimization techniques of reparative regeneration?
Criterion of assessment:
100%-86% 85%-71%
70-55%
54%-37%
10-8,6
Excellent
7-5,5Satisfactory
5,4-3,7Unsatisfactory
8,5-7,1Good
3. Analytic part
3.1. Graphic Organizers: surgical treatment Venn diagram.
Guidelines and new technology for the game
Venn diagram.
Used to compare or contrast or matching
36% и
ниже
3,6 and
below
2 - 3 aspects and show their similarities. Develops systems thinking, the ability to compare,
compare, analyze and synthesis of the policy of constructing a Venn diagram. Individually / in
pairs construct a Venn diagram and fill the hourty of disjoint circles (x). Paired, compare and complement your charts. The intersection of circles
make a list of the features that, in their view,
are common to the information of two / three laps (xx / xxx).
Repositioned and holds
the bone fragments
vneochaga fracture.
Stabilization of the
bone fragments and
optimization of
reparative
regeneration.
Allows early loading.
Allows you to control the
skin
holds
repositioned
bone fragments in the area
damage.
require to
cast
Ostesintez NKDA Ilizarov
Criterion of assessment:
Max point 20-17,2
Excellent
100%-86%
extramedullary fixation
17-14,2 ball
Good
85%-71%
3.2. Control tests and case studies.
1. The main conditions are bone fusion
A perfect reposition bone fragments
restore congruence of the articular surfaces
14-11 ball
10,8-7,4 ball
7,2 ball
Satisfactory Unsatisfactory
Bad
70-55%
54%-37%
36% and below
B. use for fixation of bone fragments low-traumatic ways
linking them dynamic compression
to the full consolidation of the fracture
B. inclusion complex of physiotherapy in the early stages
passive and active movements in the affected joints
G. Resolution in 1-2 weeks from the start of fixing the axial load
value of 30% of body weight
D. all of the above
2. The treatment of fractures may be given to the principle
A full comparison of the fragments,
restoration of function - through the restoration of the anatomy
B. high strength fixing
B. Preservation of blood supply of bone
G. save micromobility to enhance catabolic phase
regeneration of bone tissue in the fracture
D. maintain and support the affected limb motor function
3. Mechanical and physical requirements for the construction,
used for osteosynthesis in traumatology and orthopedics are
A. elasticity (elastic modulus, Young's modulus.
B. the yield stress, strength, fatigue
B. plasticity
G. wear resistance
D. all of the above
4. Exclusion lock associated
A. allergic to the metal
B. solenoid voltage tissue
B. a comminuted fracture of the nature
G. Corrosion of metals
D. correctly A. and G.
5. Corrosion prevention clips of osteosynthesis is achieved
A combination of the design clips of various metals
B. design retainer with the cyclic stress in three dimensions
V. good grinding surface of the lock
G. B. and B. correctly
D. all right
6. Well tolerated by the tissues are inert in the body,
mechanically strong and cheap alloys
A. vitallium - cobalt alloy, chromium, molybdenum,
B. tantalum
B. Zirconia
G. titanium
D. stainless steel containing molybdenum
7. Factors contributing to the corrosion fixers are
A wrong chemical composition and metallurgical processes
B. poor quality surface treatment or damage to the lock
V. joint use of different metals
The action of cyclic stresses on the metal clip
D. all of the above
8. Plate osteosynthesis prevents shifts the moment
which is
A traction force of muscles and shoulder muscles
B. fracture plane angle (in oblique fracture occurs torque)
B. mass of limb segments, located distal to the fracture site
G. shoulder mass segment
D. all of the above
In the practice of bone fixation intraosseous fixation
You can follow all of the following provisions, except
A. Introduction pin with a length of one of the fragments less than 6 cm
B. if possible, do not use short clips, long rods,
having a greater surface contact with the bone and forming
long lever arm of equal
B. hold the rods at the highest possible for a bone fragments
G. round bars are porshneobrazno and increase pressure
in the medullary canal and irritate the baroreceptors.
Flat shtykoobraznye, square bars have a large surface
contact with the bone and reduce the rotational motion
D. in periarticular fractures use 2 flat bar
with breeding them all, "directed two rod", "counter-rods"
"Simulated rods"
10. Criteria are external fixation devices are
A. The ability to accurately reposition and stable fixation of bone fragments
B. ability to provide valuable early functional treatment
B. range of possible clinical application
D. degree traumatic techniques, simplicity of design,
interchangeability and versatility of parts and components of devices
D. All of the above
11. Of Ilizarov techniques are widely used methods to
A bloodless treatment of closed and open fractures
limb lengthening
B. replacement of defects of long bones, soft tissue, blood vessels, nerves
B. at one stage a bloodless eliminate false joint, shortening,
contortion, bone deformities
G. bloodless artrodezirovat large joints, produce lengthening arthrodesis
D. all of the above
12. Hinged-distraction apparatus used
A. Development of joint movement
B. to correct axis of the limb
B. to eliminate resistant joint contractures
G. for fracture healing
D. to form the regenerator
13. For external fixation devices are all listed, except
A. Single scan with holding spokes
B. conduct a cross-spokes
B. rod
G. spokes-rod
D. Hinge
14. Adequate relationship between new growth of bone tissue,
load and the blood supply to the bone determines the rate of bone formation
The decrease in bone formation occurs by
A larger base load supply of blood circulation
B. off base load supply of blood circulation
B. maintain the original load decreases circulation
In parallel load reduction and circulation
D. increase the supporting load during the initial circulation
15. Reparative degeneration with compression-distraction osteosynthesis presented
A cartilage phase
Fibrotic phase B.
B. periosteal callus
D. A and B correctly
D. no correct answer
Criterion of assessment:
Max point 15-12,9
Excellent
100%-86%
12,75 10,65 ball
Good
85%-71%
10,5-8,25
8,1-5,55 ball
ball
Satisfactory Unsatisfactory
70-55%
54%-37%
5,4 ball
Bad
36% and below
4. The practical part
4.1. First aid in case of open fractures of the forearm bones.
Objective: To learn the technique of first aid treatment of open fractures of the forearm bones.
Specifications: Volanter, couch, aseptic napkins, bus Cramer bandage.
Performs step (stage).
Carried-out stages (steps):
№
Actions
Stages
It is not
executed (0
points)
It is
completely
correctly
executed
1.
Laying of the patient on a couch
0
10
2.
We find переде - the top awn of bones of
a basin
0
10
3.
By measure tape it is measured from the
top point through the middle of a patella
0
20
4.
The bottom point is bottom the edge of an
internal anklebone (relative length)
0
20
5.
For measurement of absolute length, we
find the top point of a big spit
0
20
6.
The bottom point is bottom the edge an
external anklebone
0
20
In total
0
100
Criterion of assessment:
Max point 40-34,4
34-28,4 ball
Excellent
100%-86%
Good
85%-71%
28 -22ball
21,6-14,8
ball
Satisfactory Unsatisfactory
70-55%
54%-37%
14,4 ball
Bad
36% and below
5. thematic and practical skills:
Form of controlling knowledge, skills and experience of students
- the oral;
- the written;
- solution of situational tasks;
- demonstration of the mastered practical skills.
5.1. Criterion of assessment of knowledge and skills of students
№
Mark
Excellent
Good
Satisfactory
Unsatisfactory
adopting %
100%86%
85%71%
70-55%
54%-37%
10,8-7,4 ball
1
Theoretical part
1.1
new pedagogic
technology
20-17,2
ball
17-14,2
ball
14-11 ball
1.2
Control question
10-8,6
8,5-7,1
7-5,5 ball
5,4-3,7 ball
Bad
36%
and
below
7,2 ball
3,6 ball
ball
2
2.1
Analytic part:
Case study
2.2
Tests
3
Practical part
ball
12,7515-12,9
10,65
ball
ball
12,7515-12,9
10,65
ball
ball
40-34,4- 34-28,4
ball
ball
10,5-8,25 ball
8,1-5,55 ball
5,4 ball
10,5-8,25 ball
8,1-5,55 ball
5,4 ball
28-22 ball
21,6-14,8 ball
14,4 ball
5.2. Criteria of an assessment of the current control on subjects « Surgical methods
of treatment in traumatology and orthopedics. Reparative regeneration of a bone
fabric »
№
activity %
Mark
1
96-100%
Excellent
“5”
2
91-95%
Excellent
“5”
3
86- 90%
Excellent
“5”
4
76-80%
Good
“4”
Level of knowledge of the student
Depending on a situation can make the
correct decision and sums up.
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
By preparation for a practical training uses
additional literature (as on native, and in
English)
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%
Good
Practical skill carries out on steps.
“4”
6
66-70%
Satisfactory
“3”
7
61-65%
Satisfactory
“3”
8
55-60%
Satisfactory
“3”
9
30-54%
unsatisfactory
“2”
Correctly collects the anamnesis, examines
the patient, makes the preliminary diagnosis.
Can interpret these laboratory researches.
Actively participates in SRS discussion.
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.
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
The ODE has no exact representation of the
basic principles inspection of patients with
damages and diseases.
10
20-30%
unsatisfactory
“2”
Doesn't know AFO of bone and muscular
system.
SRS – Feature of fractures of bones at children.
1. To make definition of an ischemic contracture of Folkman?
2. Methods of its diagnostics?
3. Elimination of an ischemic contracture of Folkman at injury of the top
extremity?
6. 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.
4. Sport medicine: book for students– М.: Gumanit. press. centre. Vlados, 1998. –
480 p.
Internet resourse; WWW.minzdrav.uz WWW.tma.uz. htt://web.tma TMA Wi-Fi
zone ZiyONet: travmo_tma@mail.ru.