Голень – это часть нижней конечности, которая располагается между коленным и голеностопным суставом. Ее составляющим считают большеберцовую и малоберцовую кость, которые часто подвергаются повреждениям.
Перелом голени – довольно распространенная травма в медицинской практике, которой чаще всего подвергаются пожилые люди, дети, спортсмены и люди с различными заболеваниями, которые влияют на ухудшение структуры костей (туберкулез, остеомиелит, рак костей и т.п.).
Существуют несколько видов повреждения:
- открытый перелом;
- закрытый перелом голени;
- оскольчатые и многоскольчатые травмы;
- со смещением отломков кости и без них.
Причины возникновения
Чаще всего подобная травма происходит в зимнюю пору года от усиленного воздействия в область голени. Также данное повреждение происходит, если человек подвержен таким заболеваниям как, например, злокачественная опухоль костных тканей, остеомиелит, туберкулез или остеопороз. При таких болезнях прочность костной ткани значительно ухудшается, и перелом может произойти даже в результате слабого воздействия на кость.
Также существуют такие причины появления подобной травмы:
- прямое или непрямое травматическое воздействие на голень;
- падение в возвышенности;
- усиленное давление на кость;
- несоблюдение всевозможных правил безопасности;
- огнестрельное ранение;
- травмы на производстве;
- занятия любым видом спорта;
- занятия боевыми искусствами.
Симптоматика
При переломах голени первые признаки могут отличаться друг от друга в зависимости от места, где произошла травма. Но существуют и основные симптомы, которые присутствуют при любом подобном повреждении:
- сильные болевые ощущения в области ушиба;
- возникновение отечности мягких тканей;
- возможно образование кровоподтеков и гематом в поврежденном месте;
- ухудшение двигательных функций травмированной конечности;
- невозможность опереться на ушибленную ногу;
- боль усиливается при любых нагрузках, движениях и при проведении процедуры пальпации;
- при движении конечностью характерный хруст костных фрагментов;
- визуальная деформация ноги в области травмы;
- кровотечение и рана с выпирающей костью (в случае открытого перелома).
Если произошел перелом лодыжки, то нижняя часть ноги (стопа) подвергается отечности, визуальной деформации кости кнаружи или кнутри, а также при таком повреждении присутствует ярко выраженный болевой синдром, а движение ноги, как и опора на нее становится невозможной.
Оказание первой медицинской помощи
Первая помощь при переломе голени – это очень важный этап, который требует серьезного подхода к нему. При правильном оказании неотложной помощи можно облегчить предстоящее лечение и обезопасить пострадавшего от развития всевозможных последствий.
Как известно, у всех людей болевой порог очень разный. У некоторых при переломе костей боль будет вполне терпимой, а некоторые могут подвергаться интенсивным болям, которые в результате поспособствуют появлению болевого шока или всевозможных проблем с сердцем. Чтобы избежать подобных осложнений первое и самое важное, что нужно сделать – дать пострадавшему ненаркотическое болеутоляющее средство, к которому имеется доступ. Главное в этом случае – убедится, что пострадавший не будет подвержен аллергической реакции после принятия медикаментозного препарата.
Далее, если произошел открытый перелом, необходимо остановить кровоизлияние и обеззаразить возникшую рану. Для того, чтобы остановить поток крови – налаживается жгут чуть выше уровня раненой области. В качестве жгута принято использовать различные подручные средства: платки, веревки, шарфы и ремни. На повязке отмечается точное время ее наложения, это делается для того, чтобы не передержать жгут и не спровоцировать омертвение конечности (оно происходит после часа использования). В случае, если кожа приобретает синий оттенок в области наложенного жгута – ослабьте повязку. После остановки кровотечения раненую поверхность необходимо обработать с помощью любых антисептических препаратов и наложить стерильную повязку или бинт, чтобы избежать дальнейшего попадания инфекции в рану.
После проделанных вышеперечисленных манипуляций травмированную конечность необходимо зафиксировать в одном правильном положении. Главное, что нужно запомнить – ни в коем случае не пытайтесь самостоятельно сопоставить смещенные фрагменты кости или удалить отломленные ее частички (в случае открытого перелома). Эти действия могут наоборот усугубить и так неприятную ситуацию.
Для иммобилизации ноги сначала необходимо положить пострадавшего в максимально удобную позу, свести к минимуму возможные движения и нагрузки на конечность. Далее для обездвиживания на ногу накладывается шина, которая должна удерживать ногу выше и ниже поврежденной области (чаще всего фиксируется нога от бедра и до стопы). В качестве фиксаторов можно использовать любые подручные средства, которые подходят по размеру и являются достаточно прочными (деревянные палки, доски и т.п.). Крепятся обездвиживающие предметы с помощью всевозможных окружающих вас предметов: веревок, тряпок, резинок, шарфов и т.д.
После того, как при переломе голени первая помощь будет оказана – вызовите врачей или самостоятельно отправляйтесь в медицинское учреждение, где опытные специалисты проведут необходимое обследование, поставят точный диагноз и назначат наиболее эффективное лечение.
Диагностические методы
После прибытия в мед. учреждение травматолог производит опрос пациента, в котором выясняется причина происхождения перелома и первые признаки. Также проводится пальпация, которая помогает определить место локализации травмы и ее вид. Для более точного диагноза назначается диагностика с помощью рентгенографии. После получения результатов врач с точностью может поставить диагноз и назначить подходящее и максимально эффективное лечение. В более тяжелых случаях может понадобиться диагностика с использованием компьютерной и магнитно-резонансной томографии.
Лечебная тактика
В легких случаях переломов лечение заключается в том, что врач производит прочное сопоставление костных фрагментов (репозиция) и фиксирует поврежденную конечность в одном положении с помощью гипсовой повязки или других фиксирующих приспособлений. Период иммобилизации длится в зависимости от вида травмы и ее характера и назначается доктором индивидуально для каждого. Снятие гипса происходит после полного восстановления структуры кости.
В случае, если травма произошла со значительным смещением, полным или неполным раздроблением кости или перелом открытого типа – проводят операцию под местной анестезией. Хирургическое вмешательство также заключается в репозиции костных отломков с помощью специальных металлических спиц, пластин и винтов.
Если перелом многооскольчатый, то врачи удаляют фрагменты отломленной кости. После завершения операции нога также подвергается фиксации на назначенный доктором срок. Металлоконструкции удаляются после полной регенерации костной ткани.
После того, как лечение будет завершено – врачом назначается начало реабилитационного периода, который поспособствует полному восстановлению двигательных функций конечности.
Осложнения после травмы
При несвоевременном лечении или несоблюдении рекомендаций вашего лечащего врача могут возникнуть такие последствия:
- хронические болевые ощущения;
- неполное или неправильное сращивание сломанной кости;
- визуальная деформация травмированного места;
- повреждение нервных окончаний;
- развитие гангрены;
- возникновение ложного сустава;
- занесение неблагоприятных инфекций (в результате открытого перелома);
- неполное восстановление работоспособности ноги;
- появление остеомиелита.
Общая клиническая картина
Специалисты выделяют ряд общих признаков:
- онемение нижних конечностей;
- сильно выраженный болевой синдром, локализующийся не в зоне повреждения, а чуть выше или ниже;
- приступы тошноты, головокружения и общая слабость;
- озноб;
- нарушение подвижности сустава.
Клиническая картина развивается достаточно быстро – в течение получаса после травмы.
Если у больного сложная форма перелома, можно наблюдать дополнительно такую симптоматику:
- побледнение кожных покровов из-за повреждения сосудов, структуры нервов;
- онемение стопы и голеностопа в целом;
- деформация конечности.
Переломы и их классификация
Нарушения целостности костей бывают двух типов:
- открытые – с разрывом мягких тканей и кожных покровов. Из раны видны осколки костей, идет кровь;
- закрытые – разрывов кожи нет, кровотечения не наблюдается.
В ряде случаев осколки костей могут смещаться. Согласно этому фактору выделяют перелом со смещением и без.
Классифицируют повреждения также по локализации травмы. Выделяют переломы:
- наружной лодыжки;
- внутренней лодыжки.
Существуют и другие классификации.
1. Перелом верхней трети голени:
2. Перелом средней трети голени (диафизарный):
- Перелом большеберцовой;
- Перелом малоберцовой;
- Укорочение конечности;
- Перелом обеих костей голени.
3. Перелом нижней трети голени:
- Перелом медиальной лодыжки;
- Перелом латеральной лодыжки;
- Двухлодыжечный перелом.
В зависимости от поврежения кожных покровов делят переломы на:
- Открытый;
- Закрытый.
По механизму травмы разделяют:
- Перелом со смещением;
- Перелом без смещения;
- Винтообразный (для малоберцовой);
- Вколоченный (для большеберцовой кости);
- Оскольчатый;
- Перелом у детей по типу зеленой ветки.
Симптомы и признаки
Существует несколько видов переломов голени: внутрисуставные, тела и лодыжек. При внутрисуставном переломе в области коленного сустава регистрируются такие симптомы:
- Выраженный болевой;
- Отечность коленного сустава, увеличение его в объеме;
- Нарушение движения в конечности, вынужденное согнутое положение ноги;
- Возможно кровоизлияние в сустав при повреждении сосудистого сплетения;
- При повреждении периферических нервных волокон – кожные парестезии;
- Голень может быть ротирована (повернута) кнаружи или кнутри.
При переломе тела кости:
- Видимая деформация костной оси;
- Отек;
- Возможные кровоподтеки;
- Болевой синдром;
- Крепитация при смещении отломков;
- Нарушения функции конечности.
Переломы лодыжек сопровождаются:
- Болевым синдромом;
- Стопа пронирована или супинирована (повернута кнутри или кнаружи);
- Невозможность движений в стопе, вследствие выраженного болевого синдрома;
- Крепитация при смещении отломков;
- Отечность и кровоподтеки в области голеностопа.
К сожалению, бывает довольно сложно понять, что случился именно перелом. Сделать это можно только при помощи рентгенографии. Поэтому не стоит рисковать и обязательно нужно зафиксировать конечность, если у пострадавшего есть такие симптомы:
- Необычная форма нижней части ноги. Она может находиться под необычным углом, либо сильно искривлена.
- Аномальная подвижность кости там, где её быть не должно.
- Хруст, который слышен на расстоянии. Этот симптом называется крепитацией.
- Отёк.
- Сильная и острая боль.
- Укорочение конечности.
- Ограничение подвижности.
Диагностировать проще всего открытую форму. Именно она считается довольно сложной для лечения.
Лечение
Выбор метода лечения при переломе голени зависит от места перелома, его тяжести, поражения прилежащих тканей и тяжести состояния самого больного, в том числе и преморбидный фон (сопутствующая патология).
Консервативно путем наложения гипсовой повязки лечатся только неосложненные закрытые переломы без смещения. Все остальные переломы необходимо лечить оперативным методом. Показания к оперативному лечению следующие:
- Двойной перелом большеберцовой, со смещением отломков;
- Кровотечение при открытом переломе;
- Открытый перелом;
- Ущемление или повреждение нервов или сосудов отломками.
Лечение закрытого перелома голени без кровотечения проводится в стационаре. Если не произошло смещение отломков кости или сломана только малая большеберцовая кость, то проводится наложение гипсовой повязки, и пациент отправляется на домашнее лечение.
Если же сломана и большеберцовая и малоберцовая кости, а также имеются смещения, тогда следует проводить оперативное вмешательство. Если этого не сделать, то перелом может неправильно срастись, а это станет причиной нарушения функциональности конечности.
Операция
При переломе голени возможно оперативное лечение. Оперативное вмешательство производится под общим наркозом в несколько этапов:
- Оголяется кость: для этого рассекается кожа, тупым способом разводятся мышечные волокна. При открытом переломе производится обработка раны, промывание ее, удаление сгустков крови;
- Открытым способом сопоставляются осколки кости на штифт при осколочном переломе, либо выкладываются на поверхность титановой пластины и фиксируются болтами;
- Послойно зашивают дефект в обратном порядке;
- Для лучшей иммобилизации перелом фиксируется еще и гипсовой повязкой.
Полное заживление с образованием костной мозоли происходит на 6-7 месяц. Затем решается вопрос о целесообразности пластины. Если пострадавший является пожилым человеком и перелом произошел на фоне остеопороза (дегенеративное заболевание костной ткани), то платину лучше оставить для профилактики рецидива.
Если пострадавший молод и не имеет фоновых заболеваний, ухудшающих течение перелома, то необходима повторная операция – удаление пластины.
Оказание первой помощи при переломе голени
Алгоритм при подозрении на перелом голени включает следующие пункты:
- Вызов бригады скорой медицинской помощи для транспортировки пострадавшего в травмпункт;
- Пострадавшего желательно уложить, во избежание усиления болевого синдрома и смещения отломков;
- Обезболивание желательно инъекционным нестероидным препаратом: Диклофенак, Дексалгин и др. для профилактики болевого шока;
- К месту травмы приложить пузырь со льдом для уменьшения отечности;
- При наличии открытого перелома костей голени и кровотечения и кровопотере необходимо наложение жгута в область верхней трети бедра. На зимнее время не более полутора часов, летом на полчаса больше;
- Иммобилизация конечности: с двух сторон. Производится при помощи шины Крамера или лестничной;
- Обработать края раны при открытом переломе перекисью водорода, наложить чистую повязку.
Как наложить шину
Наложении шины для транспортной иммобилизации при переломе голени входит в алгоритм оказания ПМП. Методика наложения шины включает следующие этапы:
- Освободить пострадавшую конечность от одежды: разрезать штанину, максимально щадя пораженную область;
- Для фиксации необходимо три лестничные шины (шины Крамера): одна длиною около 1,2 метра, вторая и третья — достаточно 0,5-0,8 м (можно использовать брусья, доски, палки);
- Шину необходимо обернуть мягким материалом (ватой) и зафиксировать его бинтом;
- Большую шину приложить к стопе, стопу согнуть, зафиксировать конец шины;
- По задней поверхности ноги шина проводится до задней трети бедра, фиксируя два сустава: коленный и голеностоп;
- Две меньшие по длине шины располагаются с двух сторон по медиальной и латеральной поверхности, таким образом нога находится как-бы в нише;
- Фиксируется бинтом спиральной повязкой.
Самый верный способ оказать помощь человеку, который оказался в такой ситуации, вызвать бригаду скорой помощи. Но в то время, пока вы будете ожидать приезда врачей, нужно выполнить несколько несложных манипуляций. Это даст возможность снизить боль и поддержать человека в сознании.
Следующим действием можно помочь пострадавшему:
- В первую очередь необходимо уложить пострадавшего в удобную для него позу, при этом минимально дотрагиваться к пораженной ноге, чтобы не доставлять человеку большой боли.
- Дальше нужно будет снять с переломанной ноги обувь, иначе через некоторое время нога начнет отекать, и это сделать будет очень тяжело и больно для самого пострадавшего.
- Для того, чтобы хоть немного уменьшить болевые ощущения и успокоить человека, нужно дать ему обезболивающие препараты. Если в данном случае у вас их нет, то тогда можно приложить к месту перелома лед. Он поможет немного уменьшить боль и снять отек.
- Если перелом оказался открытым, то нужно осмотреть рану на наличие в ней посторонних предметов. Если таковые имеются, нужно постараться аккуратно их извлечь. После этого с пострадавшей ноги необходимо будет снять всю одежду. Самостоятельно заниматься вправлением кости категорически запрещается! Этим могут заниматься только квалифицированные врачи с применением анестезии.
- При открытом переломе нужно будет только обработать рану раствором йода, зеленки или марганцовки. Конечно, если данное средство будет иметься у вас под рукой.
- Если из раны идет кровь, то ее необходимо остановить. Для этого можно наложить тугую повязку выше места перелома и раны. Это остановит кровь. В качестве жгута можно использовать ремень, шарф или галстук.
- Под жгут обязательно стоит положить какую-нибудь ткань. Подойдет тот же самый шарф или кусок одежды, который был снят с ноги человека.
- Когда вы оставляете жгут на ноге, рядом с ним обязательно нужно оставить записку, в которой указать время его наложения. Очень важно, чтобы нога была перевязана не больше двух часов. Иначе можно навредить.
- Необходимо зафиксировать ногу так, чтобы она максимально находилась в обездвиженном состоянии. Нужно это делать от бедра и до самой голени.
- Чтобы положить такую шину, подойдут все предметы — палки, доски. Главное, чтобы они были прочными.
- Под шину нужно подкладывать одежду, чтобы пораженная нога не могла повредиться еще больше. Очень важно, чтобы шина не передавливала ногу и не царапала кожу.
- Самостоятельно заниматься вправлением костей не нужно. Наберитесь терпения и дождитесь врачей.
Помните: шину нужно наложить таким образом, чтобы голеностоп был надежно зафиксирован. Лучше это делать с внутренней и наружной стороны ноги. А вот крепят шину всем, что может попасться под руки: веревки, шарфы, куски ткани и так далее.
Помните: если своевременно помочь человеку, то можно избежать осложнений и снизить риск смещения костей.
Последствия
Последствия перелома голени могут быть различными. Самым грозным является повреждение перонеального (малоберцового) нерва, сопровождающееся синдромом висячей стопы.
Клинически это сопровождается хромотой и нарушением походки, затруднением при сгибании пальцев, а так же невропатиями со стороны кожи (немотивированное чувство холода, жара, озноба, чувство «ползания мурашек», зуд).
Длительная гипоксия стопы и голени при отсутствии кровоснабжения в результате травмы приводит к отмиранию тканей, некрозу, гангрене. В результате приходится ампутировать стопу или голень. Человек становится инвалидом.
Еще одним осложнением может быть неправильное сращение костей голени. При этом так же будет наблюдаться хромота, видимое укорочение. Иногда приходится переламывать костные структуры, так как они срастаются не физиологично, и сопоставлять их заново, вытягивать и раздвигать скелетным вытяжением или аппаратом Илизарова.
При попадании с открытым переломом инфекции может развиться остеомиелит. Кость заживать быстрее при инфицировании не может. Открытый перелом голени и оперативное вмешательство – прямое показание к назначению антибиотикотерапии.
Содержание статьи
- Что делать при переломе голени
- Как лечить переломы
- Что делать при переломе конечности
Лечение перелома голени
Переломы голени различаются по типу сломанной кости. Самым тяжелым для организма считается повреждение крупной большеберцовой кости. Но намного чаще встречается перелом голеностопа с вывихом.
Прежде всего, при переломе голени следует обеспечить неподвижное положение поврежденной конечности. Для этого необходимо зафиксировать ось голени. Обычно гипсовую повязку накладывают на срок от шести недель, в зависимости от тяжести травмы. При косых переломах голени нередко делают костное вытяжение. Может потребоваться и открытое сопоставление осколков сломанной кости. Если была сломана лодыжка с вывихом, следует ее вправить. При таком переломе гипс придется носить не меньше двух месяцев.
Обычно после снятия гипса пациенту приходится достаточно долго восстанавливаться и проходить различные процедуры, делать массаж, заниматься лечебной физкультурой.
Лечебная физкультура и физиотерапия
Уже в первые дни после снятия гипса можно делать самые простые физкультурные упражнения. Рекомендуется медленно поднимать больную ногу примерно на 30 градусов вверх и опускать. Упражнение на вращение стопами можно начинать делать только через несколько недель после снятия гипса. Кстати, даже обычная ходьба станет отличным упражнением для разработки голеностопа.
Также реабилитационный период должен ознаменоваться проведением физиотерапевтических процедур. Они необходимы для того, чтобы избежать атрофии мышц. Особенно рекомендованы такие процедуры как электрофорез и электростимуляция.
Витамины и народные средства
При различных переломах голени происходит повреждение мышц, которое ведет к значительной потере белка в организме. Резервы организма уходят на восстановление поврежденных тканей. Поэтому в реабилитационный период следует принимать витамины группы B и D, цинк, кальций и фосфор для образовании костной мозоли.
Можно также использовать витаминную смесь, приготовленную самостоятельно. Для изготовления смеси потребуются: лимон, курага, мед, грецкие орехи и изюм. Курагу и изюм следует замочить в холодной воде. Все перечисленные ингредиенты потребуется пропустить через мясорубку и смешать с медом и лимонным соком. Принимать такую витаминную смесь нужно три раза в день после еды по чайной ложеке. Подобное средство чрезвычайно обогащено кальцием и калием, которые способствуют быстрому восстановлению после перелома.
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