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При переломе костей голени

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17 августа 2019

При переломе голени происходит повреждение большеберцовой либо малоберцовой костей (в некоторых случаях их обеих) из-за воздействия сильных нагрузок. Эта травма является одной из самых распространенных, составляя 15% от общего числа всех переломов. Сроки срастания, методы лечения и общее течение зависит от сложности повреждения, точной локализации и состояния организма.

Классификация травм голени МКБ-10

Международный классификатор болезней (МКБ-10) включает несколько цифровых кодов для точной постановки диагноза.

  1. Поверхностная травма голени – S80. Дополнительно содержит 5 уточняющих диагнозов.
  2. Открытая рана – S81.
  3. Перелом, который затрагивает голеностопный сустав – S82 (включен и перелом лодыжки).
  4. S83 – любые повреждения капсульно-связочного аппарата.
  5. S84 – повреждение нервных окончаний голени.
  6. S85 – травмы кровеносных сосудов голени.
  7. Код при размозженной голени – S87.
  8. Вынужденная ампутация имеет значение S88.
  9. Другие неуточненные патологии этой части проходят под кодом S89.

Медики используют классификацию по месту расположения перелома – верхняя, средняя или нижняя часть кости. Переломы имеют открытый и закрытый характер, бывают со смещением осколков и без.

ВНИМАНИЕ! Наиболее опасный перелом тот, при котором отделяются и смещаются осколки. Сложность терапии вызвана близким расположением сосудов и нервов. При лечении требуется операция по репозиции костей, при осложненном течении показана обязательная установка имплантов.

Открытый перелом костей голени

Этот вид встречается чаще остальных из-за анатомического строения голени. Большеберцовая кость расположена прямо под кожей, при повреждении она прорывает ее острыми краями, вызывая открытый перелом. Среди характерных симптомов:

  • наличие зияющей раны (видна кость и участок мягких тканей);
  • кровотечение;
  • острая боль, травматический шок;
  • головокружение, возможна потеря сознания.

При открытых переломах важно экстренно оказать первую помощь, очистить рану от грязи и обработать дезинфицирующими средствами (проводить процедуры на месте, не дожидаясь скорой). В больнице уже фиксируется рана, устанавливаются дренажи.

Закрытый перелом голени

О таком повреждении говорит резкое ограничение подвижности – человек не может даже пошевелить ногой. При попытке немного приподнять ногу, конец большеберцовой кости виден под кожей. Типичный симптом закрытого перелома – крепитации (хруст) при ощупывании поврежденного места. Вызывать такой звук специально запрещено, так как это влечет риск смещения осколков. У молодых и зрелых пациентов закрытый перелом имеет расщепленный характер из-за прочной структуры костей. У пенсионеров такой перелом вдавлен, что объясняется высокой пористостью костной ткани.

Факторы тяжести переломов

Медики выделяют несколько степеней тяжести переломов голени.

В группу входит закрытый перелом без смещения осколков.

Это открытый или закрытый перелом, при котором повреждается мягкая ткань.

Одновременная травма в нескольких системах (кости, суставы, сосуды).

Факторы тяжести переломов – это конкретные действия, состояния, которые определяют характер и специфику повреждения. Перелом голени осложняет то, что рядом находятся мягкие ткани, сосуды, сухожилия и нервные корешки. Самые тяжелые травмы можно получить в ДТП либо при падении с большой высоты. Катаясь на коньках, может произойти перекручивание голени с зафиксированной стопой, что утяжеляет перелом. Также негативно влияет на травму наличие таких заболеваний, как остеомиелит или остеосаркома.

Как проходит диагностика?

Травматолог проводит осмотр и пальпацию места повреждения. Далее пациента направляют на рентген костей, который проводится в боковой и прямой проекции. При неточном диагнозе дополнительно назначается КТ и артроскопия – артроскоп (разновидность эндоскопа) вводится в голень через микроразрез. Данные диагностики определяют ход и методы лечения.

Время срастания

На итоговый срок влияет комплекс факторов, главный из которых – вид перелома. Также время зависит и от возраста: даже тяжелые переломы у детей срастаются быстрее, чем легкие повреждения у пожилых. Период восстановления медленно проходит при наличии лишнего веса, а также:

  • при хронических патологиях;
  • сезонное ослабление иммунитета;
  • другой воспалительный процесс в организме.

Средний срок полного срастания костей голени – 10-12 недель. Посторонняя поддержка при ходьбе понадобится пострадавшему еще на протяжении 4-6 недель.

Лечение переломов голени

Оперативную помощь и последующее лечение осуществляет травматолог. Выбор терапевтических тактик зависит от сложности и места расположения перелома. Общая последовательность действий врача – репозиция обломков (сопоставление фрагментов поврежденной кости), операция. В сложных ситуациях показана замена кости на имплант или вытягивание кости. Далее обязательно обеспечить полную неподвижность поврежденной голени. Для этого обычно накладывают гипс. Удерживать травмированные кости также помогает аппарат Елизарова.

Как оказывают помощь при открытом переломе? В больнице проводится полная очистка раны. При косом или винтообразном характере требуется наложить швы и зафиксировать на проволоку. Также при открытом переломе внутрь кости устанавливают стержень из металла. Приспособление внутри имеет пустую полость, по бокам – отверстия. Через него в канал поступают лекарства. После установки стержня накладывается гипс.

Как лечат закрытый перелом? Основные задачи – восстановление структуры и целостности кости, устранение боли. В целях лечения используют такие методы.

  1. Фиксация или наложение гипса.
  2. Оперативное вмешательство – внутрикостная фиксация при помощи металлической пластины, спицы или проволоки.
  3. Экстензионный или вытяжения поломанной кости.

СПРАВКА! При переломе со смещением показана репозиция – вправление и сопоставление костных фрагментов. Если процедуру провести не получается, требуется операция. После нее на протяжении 2-3 недель пациент должен провести на вытяжении кости за пяточную кость.

Период восстановления для любых переломов включает массаж со специальными кремами, ванны и восковое обертывание. Пострадавшему показаны легкие физические упражнения – плавные движения стопой, сгибание и разгибание колена. Позднее нагрузка усиливается – показаны махи ногами, длительные пешие прогулки, вращательные движения. Показатель окончания восстановления – безболезненная функциональность и подвижность травмированной кости.

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Переломы голени входят в список самых частых травм. Получить такое повреждение можно в ряде случаев: от ДТП до обычной пешей прогулки. Диагностику и лечение проводит врач-травматолог. Прогноз на выздоровление зависит от сложности, точной локализации перелома и особенностей организма пострадавшего.

Конечности являются важными частями опорно-двигательного аппарата человека. И их повреждение может не только принести дискомфорт в привычную жизнь, но и серьезно сказаться на дальнейшем образе жизни человека.

Открытый перелом голени, к сожалению, происходит так же часто, как и закрытые виды травмирования. Но ситуация может иметь ряд осложнений, например таких, как смещение или наличие осколков в мышечном скелете, который окружает кости. Важно своевременно сориентироваться при возникновении симптомов указанной травмы и обратиться за медицинской помощью.

Что может послужить причиной перелома

Голень составляют большеберцовая и малоберцовая кости. Они могут быть подвержены травмированию по ряду причин:

  • во время падения;
  • при получении удара человеком в данную область ноги;
  • попадание в ДТП;
  • при чрезмерных физических нагрузках на ноги.

Также перелом костей голени нередко возникает у спортсменов и у категории людей, объем кальция в организме которых минимален. К ним относятся пожилые люди, беременные и кормящие женщины. Подвержены такому виду травмирования и люди, страдающие заболеваниями, влияющими непосредственно на здоровье костной системы. К таким заболеваниям относятся: остеомиелит, остеопороз, туберкулез, дефекты развития опорно-двигательной системы, а также злокачественные и метастатические опухоли.

Классификация переломов

Перелом классифицируется на 2 разновидности: он может принимать открытую или закрытую форму. В первом случае разрывается мускулатура, окружающая костный скелет и кожный покров над голенью, и осколки расколотых костей выступают из раны. Закрытый перелом голени имеет следующие признаки: мышечный скелет не задет и кожа над костью также остается нетронутой, несмотря на травму. Обе разновидности переломов могут происходить как со смещением частей травмированных костей, так и без него.

В зависимости от того, какое количество разломов имеется на травмированной кости, переломы делятся на:

  • единичные – один надлом;
  • двойные – двойной надлом.

Главным симптомом двойного перелома обычно является невозможность стать на нижнюю конечность.

Симптомы

В зависимости от того, какая кость повреждена и на каком именно ее участке произошел перелом, и к какому виду он относится, симптомы травмирования могут разниться. Но общая симптоматика в случаях, когда происходят переломы костей голени, являются следующими:

  • Возникновение сильного болевого синдрома в поврежденной части тела.
  • Возникновение сильной опухоли и мгновенное распространение отечности вокруг травмированного участка ноги.
  • Возможен разрыв или надрыв кожного покрова, из которого могут быть видны осколки костей.
  • Деформация нижней конечности в той ее части, где произошел раскол костей.
  • Усиление болевого симптома во время попыток совершить двигательные движения поврежденной ногой.
  • Невозможность стать на конечность из-за сильной боли и имеющегося раскола костей.

Если у человека возникли вышеуказанные признаки перелома, необходимо оказать ему первую медицинскую помощь и вызвать бригаду специалистов.

Оказание первой медицинской помощи

При подозрении на перелом голени нужно в первую очередь обездвижить человека. А затем осуществить наложение самодельной обездвиживающей повязки (шины) на пострадавшую конечность. С этой целью можно использовать любые ровные, длинные предметы, которые окажутся рядом. Их достаточно примотать к ноге подручной одеждой, приложив их по правую и левую стороны от сломанной голени.

Если произошел открытый перелом со смещением и фрагменты костей разорвали кожу, вследствие чего открылось кровотечение, необходимо принять срочные меры по его остановке. Для этого нужно приложить к коже вокруг открывшейся раны любой холод. Это может быть лед или снег с улицы или из холодильника. Также подойдет заморозка. Любой холод сначала необходимо завернуть в ткань. После того, как кровь перестанет идти слишком сильно, рану необходимо перевязать чистой тканью или бинтами, если они окажутся рядом.

При сильном артериальном кровотечении (пульсирующая струя) обязательно наложение жгута, который предотвратит быстрые и объемные потери крови, иногда ведущие к летальному исходу. Жгут накладывается сверху от раны на 10-15 сантиметров и плотно затягивается. Под жгут помещается записка, на которой пишется точное время его наложения. Это необходимо для того, чтобы через полтора часа его ослабить и возобновить тем самым поток крови в поврежденную конечность во избежание ее отмирания. Затем жгут снова затягивается на такое же время.

Если из раны видны кости, ни в коем случае нельзя пытаться вправить их обратно, так как это может спровоцировать усиление кровотечения у пострадавшего, дополнительные разрывы мягких тканей и болевой шок. Оказав ему необходимую первую помощь, вызовите неотложную помощь и подождите ее.

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Диагностические меры

По приезду в больницу, врач осмотрит пациента в месте травмы и расспросит его о том, что произошло, вследствие чего наступило травмирование и т.д. После этого он поставит предварительный диагноз больному и отправит его на рентгенологическое обследование, а также в случае необходимости на артроскопию.

Данные исследования помогут уточнить вид перелома и выявить его локализацию. После того, как будут проведено необходимые исследования и уточнены все данные о полученном пациентом переломе голени, специалист будет принимать решение о его дальнейшем лечении.

Разновидности лечения

Переломы голени различного типа нуждаются в различном лечении. Самой простой травмой в медицине считается закрытый перелом голени, который в свою очередь не сопровождается наличием осколков и т.д., но сопровождается смещением сломанных фрагментов. В данном случае пациенту вправляют сломанные кости — действие выполняется при использовании местной или общей анестезией, после чего их фиксируют вместе при помощи наложения гипсовой повязки. Обычно, последняя накладывается на срок до 6-7 недель. На данный период времени больному назначают прием обезболивающих препаратов, продуктов обогащенных кальцием и кальция в чистом виде, который можно приобрести в аптеке.

В случаях, когда происходит перелом обеих костей голени одновременно, для их полного восстановления необходима иммобилизация на длительный период времени. Восстановление целостности костей при двойном переломе может затянуться порою на срок до 12 недель.

Скелетное вытяжение — еще один способ лечения закрытого перелома с наличием смещения. Суть заключается в вытяжении ноги под воздействием груза, который подвешивается к конечности через ранее вставленную спицу в пяточную кость. Для взрослых пациентов груз необходим весом примерно в 6 кг, а для детей он подбирается индивидуально и зависит от возраста. Полтора месяца необходимо лежать под воздействием специальной конструкции, время от времени делая рентген, чтобы отслеживать формирование костного мозоля. Когда он полностью образуется, на поврежденную конечность накладывается фиксирующее приспособление (гипс, либо его альтернатива), и носится около двух-четырех месяцев.

Открытый перелом голени со смещением и осложнением в виде находящихся в мягких тканях осколков, начинают лечить с хирургического вмешательства. Его проводят с целью соединения фрагментов костей в их естественное положение. Для этого может проводиться операция с пластиной, могут использоваться и хирургические винты, болты, петли и спицы.

Скрепление костей пластиной — остеосинтез

Также во время операции с пластиной при переломе голени со смещением зажимают поврежденные нервы и кровеносные сосуды, после чего зашивают все поврежденные мягкие ткани, а затем и саму кожу. Для фиксации костей, как при двойном переломе, так и при единичном, помимо гипсовых повязок, могут использоваться специальные туторы, ортезы.

Фиксируют кости до тех пор, пока в месте перелома не начнется образование костного мозоля. Когда рентген покажет, что костный мозоль окреп, пациенту снимут фиксирующее приспособление и назначат реабилитационные процедуры. После перелома голени образование костного мозоля обычно происходит через 6-8 недель спустя. Но сколько ходить в гипсе точно, зависит от индивидуальных особенностей организма. Иногда пациентам приходится находиться с фиксирующим приспособлением до 12 недель.

Операция с пластиной при переломе голени со смещением — это самый правильный путь, который не приведет к осложнениям и позволит пациенту быстрее стать на ногу.

Реабилитация

Главными реабилитационными мерами при различных видах переломов голени являются:

  • посещение физиотерапевтического кабинета (процедура электрофореза, магнитотерапии);
  • посещение кабинета лечебной физкультуры;
  • посещение массажного кабинета;
  • соблюдение диеты (в рацион питания в большом количестве вводятся продукты, содержащие кальций);
  • обязательная самостоятельная разработка травмированной конечности дома (самомассаж и двигательные движения).

Полноценно нагружать подвергшуюся перелому часть ноги необходимо осторожно, увеличивая нагрузки через временные промежутки. Не стоит чрезмерно торопиться, чтобы кости не были сломаны повторно.

Переломы костей голени — это одновременное нарушение целостности большеберцовой и малоберцовой костей. Проявляются болью, нарушением конфигурации и патологической подвижностью голени, невозможностью опоры на ногу. Диагностика осуществляется путем рентгенографического исследования. Внутрисуставные переломы требуют дополнительного проведения КТ или МРТ сустава. Лечение переломов голени состоит в репозиции отломков, наложении гипсовой повязки или скелетного вытяжения. Для фиксации отломков может потребоваться операция с применением металлических пластин или винтов, установка аппарата Илизарова.

МКБ-10

Общие сведения

Переломы костей голени составляют 10% от общего числа переломов. Течение, методы и сроки лечения зависят от уровня и объема повреждения и отличаются при переломах костей голени различной локализации.

Патанатомия

Голень – часть скелета между бедром и стопой, состоящая из двух трубчатых костей (большеберцовой и малоберцовой). Основную нагрузку несет на себе более крупная большеберцовая кость. Мыщелки (выступы в верхней части большеберцовой кости) соединяются с бедренной костью, образуя нижнюю суставную поверхность коленного сустава. Своей нижней частью большеберцовая кость сочленяется с таранной костью, образуя голеностопный сустав.

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Малоберцовая кость располагается с наружной стороны, увеличивает стабильность и прочность голени. Обе кости голени соединяются между собой (вверху – при помощи общего сочленения, в средней части – посредством межкостной мембраны, внизу – при помощи связок). На нижних концах обеих костей голени имеются выступы (лодыжки), которые с двух сторон охватывают голеностопный сустав и придают ему поперечную стабильность.

Классификация

В зависимости от локализации в травматологии и ортопедии различают:

  • переломы костей голени в ее верхней части (переломы шейки и головки малоберцовой кости, переломы бугристости и мыщелков большеберцовой кости);
  • переломы костей голени в ее средней части (изолированные диафизарные переломы большеберцовой и малоберцовой кости, переломы диафизов обеих костей голени);
  • переломы костей голени в ее нижней части (переломы лодыжек).

Переломы костей голени в верхних и нижних отделах относятся к группе внутри- или околосуставных переломов.

Виды переломов голени

Переломы мыщелков

Обычно возникают при падении с высоты. У молодых пациентов чаще бывают расщепленными, у пожилых – вдавленными. Выделяют переломы внутреннего и наружного мыщелков.

Пациент предъявляет жалобы на боли и отек в области повреждения. Коленный сустав увеличен в объеме в результате гемартроза (скопления крови). Перелом наружного мыщелка сопровождается поворотом голени кнаружи, перелом внутреннего мыщелка – отклонением голени кнутри. Движения в суставе резко болезненны, ограничены. Опора на ногу невозможна или затруднена. Для подтверждения выполняется рентгенография, МРТ коленного сустава.

Лечение:

Перелом большеберцовой кости обезболивают, при необходимости проводят пункцию сустава. При переломе мыщелков без смещения накладывают гипсовую повязку на 1 месяц. По окончании иммобилизации назначают физиолечение и лечебную физкультуру. Полную нагрузку разрешают через 2 месяца с момента травмы.

При переломах мыщелков со смещением выполняют репозицию и накладывают гипсовую лонгету на 6-7 недель. При невозможности удовлетворительного сопоставления отломков проводят скелетное вытяжение сроком до 2 месяцев. Полную нагрузку разрешают через 3 месяца с момента травмы. Возможно оперативное лечение с использованием винтов, пластин и аппарата Илизарова.

Диафизарные переломы

Перелом диафиза большеберцовой кости является результатом прямой или непрямой травмы. Если межкостная мембрана остается неповрежденной, смещения отломков по длине не возникает. Возможно угловое смещение и смещение по ширине.

Пациента беспокоит боль и отек в области повреждения. Голень деформирована. Опора на ногу невозможна. Для подтверждения делают рентгенографию в двух проекциях.

Выполняют обезболивание места перелома. При смещении отломков проводят репозицию с последующим наложением гипсовой лонгеты сроком на 2 месяца. При интерпозиции мягких тканей (вклинивании тканей между отломками) необходима операция.

Перелом диафиза малоберцовой кости развивается вследствие прямого удара по голени снаружи. Травма сопровождается болью в месте перелома и незначительным отеком. Пациент сохраняет возможность опираться на ногу. В отличие от ушиба голени, при переломе малоберцовой кости появляется болезненность при боковом сжатии голени вдали от места повреждения. Для подтверждения выполняют рентгенографию. Больному накладывают гипсовую лонгету на 3-4 недели.

Диафизарный перелом обеих костей голени возникает при ударе по голени («бамперный перелом» при дорожном происшествии) или непрямой травме (скручивание, сгибание). Прямая травма обычно становится причиной многооскольчатых переломов костей голени. При сгибании образуется треугольный осколок на внутренней стороне искривления, а при скручивании возникают винтообразные переломы костей голени.

Пациент жалуется на резкую боль в области повреждения. Голень отечна, синюшна, деформирована. Наблюдается отклонение стопы кнаружи. Определяется крепитация и патологическая подвижность отломков. Опора на поврежденную ногу невозможна. Для подтверждения выполняют рентгенографию в двух проекциях.

При переломах костей голени без смещения, возможности отрепонировать отломки и удержать их в правильном положении проводят скелетное вытяжение в течение 4 недель. Затем накладывают гипсовую лонгету сроком на 3-4 месяца. При невозможности сопоставить и удержать отломки, интерпозиции мягких тканей, а также для сокращения сроков лечения и ранней активизации больного врачи-травматологи применяют оперативное лечение. Используются винты, блокируемые стержни, винты и аппараты наружной фиксации.

Переломы лодыжек

Составляют примерно 60% от общего числа переломов костей голени. Появляются в результате прямой (удар по лодыжке) и непрямой (форсированный поворот, подворачивание стопы кнутри или кнаружи) травмы. Возможны:

  • изолированные переломы внутренней и наружной лодыжки;
  • двухлодыжечные переломы (переломы обеих лодыжек);
  • двухлодыжечные переломы в сочетании с переломом переднего или заднего края большеберцовой кости (переломы Потта-Десто, другое название – «трехлодыжечные переломы»).

Любые переломы лодыжек могут сопровождаться разрывом связок, смещением отломков и подвывихом стопы (переломовывихи), однако, чаще такие повреждения наблюдаются при двух- и трехлодыжечных переломах. Для перелома наружной лодыжки характерен подвывих стопы кнутри, для перелома внутренней лодыжки – подвывих стопы кнаружи.

Голеностопный сустав отечен, резко болезненен. Опора на ногу затруднена, при переломовывихах невозможна. При переломовывихах наблюдается отклонение стопы в соответствующую сторону, при переломах Потта-Десто – сгибание стопы в подошвенную сторону. Для подтверждения диагноза выполняют рентгенографию в двух, иногда – в трех проекциях.

Лечение

Анестезия перелома, репозиция, наложение гипсовой лонгеты. При переломе одной лодыжки без смещения срок иммобилизации составляет 4 недели, при двухлодыжечных переломах (в том числе – с подвывихом стопы) – 8 недель, при переломах Потта-Десто и разрывах межберцового синдесмоза – 12 недель. Операция показана при невозможности сопоставления костных фрагментов и интерпозиции мягких тканей.

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