Operative surgery and clinical
anatomy of the upper and
lower limbs. Operative
interventions on the joints
and bones of the extremities.
The upper limb is made up of four parts
with further subdivisions:
1. shoulder region – axilla, scapular
region, pectoral region, deltoid region;
2. arm or brachium – anterior region,
posterior region;
3. elbow;
4. forearm or antebrachium – anterior
region, posterior region;
5. hand or manus – palm, dorsum, fingers
or digits.
scapular region
Quadrangular space.
Boundaries
Superior:
- Subscapularis in front.
- Capsule of the shoulder joint .
- Inferior border of teres minor behind .
Inferior: Superior border of
teres major.
Medial: Lateral border
of long head of the triceps
brachii.
Lateral: Surgical neck of
the humerus.
Contents
- Axillary nerve.
- Posterior circumflex
humeral vessels.
Quadrangular space
This is a clinically important anatomic space
in the arm. In the quadrangular space, the
axillary nerve and posterior circumflex
humeral artery can be compressed or
damaged due to space-occupying lesions or
disruption in the anatomy due to trauma.
Symptoms include axillary nerve related
weakness of the deltoid muscle in the case of
any significant mass lesions in the
quadrangular space.
Upper triangular Spase Lower triangular Spase
Boundaries Boundaries
Superior: Inferior border of teres Medial: Lateral border of long head of
minor . the triceps brachii.
Inferior: Superior border of teres Superior: Lower border of teres major .
major. Lateral: Midial border of humerus.
Lateral: Midial border of long head Contents
of the triceps brachii. - Radial nerve.
Contents - Profunda brachii vessels.
Circumflex scapular artery. It
interrupts the origin of the
teres minor and reaches
infraspinous fossa for
anastomoses with the
suprascapular artery.
Axilla region
The axilla contains the principal vessels
and nerves to the upper limb and many
lymph nodes.
Contents of Axilla:
The axilla contains the axillary vessels, the
infraclavicular part of the brachial plexus and its
branches, lateral branches of some intercostal
nerves, many lymph nodes and vessels, loose
adipose areolar tissue and, in many instances, the
‘axillary tail’ of the breast. The axillary vessels and
brachial plexus run from the apex to the base along
the lateral wall, nearer to the anterior wall: the
axillary vein is anteromedial to the artery. The
obliquity of the upper ribs means that the
neurovascular bundle, after it emerges from behind
the clavicle, crosses the first intercostal space: its
relations are therefore different at upper and lower
levels.
Axillary artery
Axillary artery is the continuation
of the subclavian. It extends from
the outer border of the first rib to
the lower border of the teres major
muscle where it continues as the
brachial artery. Its direction varies
with the position of the arm.
The pectoralis minor muscle
crosses the artery and divides it
into three parts:
- First part, superior (proximal) to
the muscle.
- Second part, posterior (deep) to
the muscle.
- Third part, inferior (distal) to the
muscle.
The axillary artery gives
six branches:
- superior thoracic artery
- thoracoacromial artery
- lateral thoracic artery
- anterior circumflex
humeral artery
- posterior circumflex
humeral artery
- subscapular artery
brachial artery
Arteries of the Anterior Fascial
Compartment of the Forearm
Ulnar Artery Branches
The ulnar artery is the larger of the 1. Muscular branches to neighboring
two terminal branches of the muscles.
brachial artery. It begins in the 2. Recurrent branches that take part in
cubital fossa at the level of the neck the arterial anastomosis around the
of the radius. It descends through elbow joint.
the anterior compartment of the 3. Branches that take part in the
forearm and enters the palm in front arterial anastomosis around the wrist
of the flexor retinaculum in company joint.
with the ulnar nerve. It ends by 4. The common interosseous artery,
forming the superficial palmar arch, which arises from the upper part of the
often anastomosing with the ulnar artery and after a brief course
superficial palmar branch of the divides into the anterior and posterior
radial artery. interosseous arteries. The interosseus
arteries are distributed to the muscles
lying in front and behind the
interosseous membrane; they provide
nutrient arteries to the radius and ulna
bone.
RADIAL ARTERY
It begins in the cubital fossa at the
level of the neck of the radius. It
passes downward and laterally,
beneath the brachioradialis muscle
and resting on the deep muscles of the
forearm. In the middle third of its
Branches in the Forearm
course, the superficial branch of the
1. Muscular branches to
radial nerve lies on its lateral side. In
neighboring muscles.
the distal part of the forearm, the radial
2. Recurrent branch, which takes
artery lies on the anterior surface of
part in the arterial anastomosis
the radius and is covered only by skin
around the elbow joint.
and fascia. Here, the artery has the
3. Superficial palmar branch,
tendon of brachioradialis on its lateral
which arises just above the wrist,
side and the tendon of flexor carpi
enters the palm of the hand, and
radialis on its medial side (site for
frequently joins the ulnar artery to
taking the radial pulse). The radial
form the superficial palmar arch.
artery leaves the forearm by winding
around the lateral aspect of the wrist to
reach the posterior surface of the
hand.
Arteries of the Posterior Fascial Compartment of
the Forearm
The anterior and posterior interosseous arteries arise from the
common interosseous artery, a branch of the ulnar artery. They pass
downward on the anterior and posterior surfaces of the interosseous
membrane, respectively, and supply the adjoining muscles and
bones. They end by taking part in the anastomosis around the wrist
joint.
FORMATION OF THE BRACHIAL
PLEXUS
Roots
The ventral rami of spinal nerves C5 to T1
are referred to as the roots of the plexus.
Trunks
Shortly after emerging from the
intervertebral foramina , these 5 roots unite
to form three trunks.
The ventral rami of C5 & C6 unite to form
the Upper Trunk.
The ventral ramus of C 7 continues as the
Middle Trunk.
The ventral rami of C 8 & T 1 unite to form
the Lower Trunk.
Each trunk splits into an anterior
division and a posterior division.
The anterior divisions usually supply
flexor muscles.
The posterior divisions usually supply
extensor muscles.
Cords
The anterior divisions of the
upper and middle trunks unite to
form the lateral cord.
The anterior division of the
lower trunk forms the medial
cord.
All 3 posterior divisions from
each of the 3 cords all unite to
form the posterior cord.
The cords are named according to their
position relative to the axillary artery.
Terminal Branches are mixed nerves
containing both sensory and motor
axons.
Musculocutaneous nerve is derived from the lateral cord.
This nerve innervates the muscles in the flexor compartment
of the arm.
Carries sensation from the lateral (radial) side of the
forearm.
Ulnar nerve is derived from the medial cord.
Motor innervation is mainly to intrinsic muscles of the hand
Sensory innervation is from the medial (ulnar) 1 & 1/2 digits
(the 5th. and 1/2 of the 4th. digits).
Median nerve is derived from both the lateral and medial
cords.
Motor innervation is to most of the flexors muscles in the
forearm and intrinsic muscles of the thumb (thenar muscles).
Sensory innervation is from the lateral (radial) 3 & 1/2 digits
(the thumb and first 2 and 1/2 fingers).
Axillary nerve is derived from the posterior cord.
Motor innervation is deltoid and teres minor
muscles that act on the shoulder joint.
Radial nerve is also derived from the posterior
cord.
Called “Great Extensor Nerve” because it
innervates the extensor muscles of the elbow, wrist
and fingers.
Sensory innervation is from the skin on the dorsum
of the hand on the radial side.
Radial (C 5 – T1)
Drop Wrist – Extensor carpi
radialis longus & brevis, Ext.
carpi ulnaris.
Difficulty making a fist – synergy
between wrist extensors and
finger flexors.
Ulnar (C 8, T1)
“Clawing” of fingers 3 & 4- M.P. joints
hyper extended; P.I.P. Flexed –
Interossei & Lumbricals.
Loss of abduction & adduction of M.P.
joints of fingers –Interossei.
Thumb – abducted and extended –
adductor polices.
Loss of flexion of D.I.P. joints of fingers
4 & 5 – Fl. digit profund.
Median (C 5 – T1)
Pronation of radioulnar joints-Pronator teres & quadratus.
Weak wrist flexion – Fl. carpi radialis.
Weakened opposition of thumb – thenar muscles.
“Ape Hand”- thumb hyper extended and adducted – thenar
muscles
“Papal Hand” Loss of flexion of I.P. joints of thumb & fingers 1 & 2 –
Fl. pollices longus ; Fl. digit. superficialis, Fl. digit profundus.
Weakened opposition of thumb – thenar muscles
Lower Limbs
Femoral Canal
a short diverticulum within the
femoral sheath that extends distal to
the inguinal ligament on the medial
side of the femoral vessels; its
boundaries are:
medial – lacunar ligament;
lateral – fascia on the femoral vein;
anterior – inguinal ligament;
posterior – fascia on the pectineus m.
Femoral canal is the medial
compartment of the femoral sheath; it
opens into the abdominal cavity
superiorly at the femoral ring;
it may be the site of a femoral hernia;
usually contains a deep inguinal
lymph node (gland of Cloquet)
The vascular lacuna (Latin: lacuna vasorum) is the
medial compartment beneath the inguinal ligament, for
the passage to the femoral vessels, lymph node, and
femoral branch of the genitofemoral nerve. Medial to
lateral these are the: Rosenmuller lymph node, femoral
vein, femoral artery, and femoral branch of
genitofemoral nerve. It is separated from the muscular
lacuna by the iliopectineal arch. It's boundaries are
therefore the iliopectineal arch, the inguinal ligament,
lacunar ligament and superior border of the pubis. The
lacunar ligament can be a site of entrapment for
femoral hernias.
The Muscular lacuna (Latin: lacuna musculorum) is
the lateral compartment beneath the inguinal ligament,
for the passage of the iliopsoas muscle and femoral
nerve; it is separated by the iliopectineal arch from the
vascular lacuna.
Femoral Ring
opening into the femoral canal;
its boundaries are:
medial – lacunar ligament,
lateral – fascia on the femoral
vein,
anterior – inguinal ligament,
posterior – fascia on the
pectineus m.
If a femoral hernia develops,
the herniated gut passes
through the femoral ring.
Femoral Triangle
a musculo-fascial triangle on
the anterior surface of the thigh;
its boundaries are:
superior – inguinal ligament,
lateral – sartorius m.,
medial – medial edge of the
adductor longus m.
femoral triangle contains the
femoral a., v. and n.
Adductor Canal
a musculo-fascial canal that contains the large neurovascular
bundle of the anterior thigh; its boundaries are: anterior – sartorius
m.; lateral – vastus medialis m.; posterior – adductor longus m. and
adductor magnus m.; it begins proximally at the inferior angle of the
femoral triangle and ends distally at the adductor hiatus.
Adductor canal contains
the femoral a. and v.,
the saphenous n. and the nerve
to the vastus medialis m.;
also known as: Hunter's canal,
subsartorial canal .
Adductor Hiatus
an opening in the tendon of insertion
of the adductor magnus m.; its
boundaries are:
medial – portion of the tendon of
adductor magnus that attaches to the
adductor tubercle,
lateral – insertion of the adductor
magnus into the linea aspera,
inferior – femur femoral a. and v. pass
through the adductor hiatus to reach
the posterior surface of the knee,
where their name changes to popliteal
a. and v.
Fascia Lata
deep fascia forming a tubular investment
of the thigh fascia lata is thickened
laterally to form the iliotibial tract/band; it
is connected to the femur by the lateral
and medial intermuscular septa which
divide the thigh into compartments;
Scarpa's fascia attaches to the external
surface of the fascia lata inferior to the
inguinal ligament.
Anterior compartment, thigh
a connective tissue compartment that
contains muscles that extend the
knee; its boundaries are: anterior and
lateral – fascia lata of the thigh;
posterior - femur, medial intermuscular
septum and lateral intermuscular
septum.
Anterior compartment of the thigh
contains the quadriceps femoris [Link]
sartorius m.; also known as extensor
compartment of the thigh.
Medial compartment, thigh
a connective tissue compartment that
contains the muscles that adduct the
thigh; its boundaries are:
anterior – medial intermuscular
septum;
posterior – fascia between the medial
and posterior compartments;
medial – fascial lata;
lateral – femur.
Medial compartment of the thigh
contains: pectineus m., adductor
longus m., adductor brevis m.,
adductor magnus m., gracilis m.,
obturator externus m.; also known
as: adductor compartment of the
thigh.
Posterior compartment, thigh
a connective tissue compartment that
contains the muscles that flex the knee
joint and extend the hip joint; its
boundaries are: anterior – lateral
intermuscular septum, femur and
fascia between the medial and
posterior compartments; lateral,
medial and posterior – fascia lata.
Posterior compartment of the thigh
contains: semimembranosus m.,
semitendinosus m., biceps femoris m.;
sciatic nerve; also known as:
hamstring compartment.
Fascia, Crural
deep fascia forming a tubular
investment of the leg crural fascia is
continuous with the fascia lata at the
level of the knee; it is connected to the
fibula by the anterior and posterior
intermuscular septa; crural fascia is
thickened near the ankle to form the
extensor and flexor retinacula.
Blood supply of knee joint
There is a complex anastomosis
around the patella and condyles of
tibia and femur. This anastomosis
consists of a superficial network and a
deep network. The superficial network
spreads between the fascia and the
skin around patella. It also supplies the
fat deep to patellar tendon. The deep
network lies on the femur and tibia
near the adjoining articular surfaces,
and supplies the bone, the joint
capsule, synovial membrane and the
cruciate ligaments.
The arteries involved are superior,
middle and inferior genicular branches
of popliteal artery, descending
genicular branches of femoral artery,
lateral circumflex femoral artery and
the circumflex fibular artery.
The venous drainage
corresponds in name to the arterial
supply and runs with it. The smaller
veins eventually drain into the femoral
and popliteal veins.
Nerve Supply to knee joint
The knee joint receives its nerve
supply from branches of the obturator,
femoral, tibial and common peroneal
nerves.
Femoral Artery Location
The femoral artery lies at the mid-
inguinal point, which lies midway
between pubic symphysis and the
anterior superior iliac spine. The
line between the middle of the
inguinal ligament and medial
condyl is the Ken [Link] surface
anatomy of the femoral vein is
identified for venipuncture by
palpating the point of maximal
pulsation of the femoral artery
immediately below the level of the
inguinal ligament and marking a
point approximately 0.5 cm medial
to this pulsation.
Foramina of gluteal region
Greater sciatic foramen:
The greater sciatic foramen is formed
anteriorly and laterally by the ilium bone,
medially by the sacrum, inferiorly by the
sacrospinous ligament .The greater sciatic
foramen provides an exit from the pelvis into
the gluteal region and structures that come
from pelvis into the leg pass through this
foramen.
The following structures pass through this
foramen.
• Prirformis muscle
• Sciatic nerve
• Posterior Cutaneous nerve of thigh
• Superior and inferior gluteal nerves
• Nerves to obturator internus muscle and
quadratus femoris muscle
• Pudendal nerve
• Superior and inferior gluteal arteries
• Internal pudendal artery and vein
Foramina of gluteal region
When the piriformis muscle leaves the
pelvis, it divides the greater sciatic
foramen on the suprapiriformis recess
and the infrapiriformis recess.
SCIATIC NERVE
The sciatic nerve is composed
of nerve roots derived from the
sacral plexus in the lumbar
region and runs through the
buttock and down the lower
limb. It is the longest and widest
single nerve in the body.
The nerve enters the lower limb by
exiting the pelvis through the greater
sciatic foramen, below the piriformis
muscle and above the superior
gemellus muscle.
It descends midway in the greater
trochanter of the femur and the
tuberosity of the ischium, and along
the back of the thigh to about its lower
third, where it divides into two large
branches, the tibial and common
peroneal nerves. This division may
take place at any point between the
sacral plexus and the lower third of the
thigh.
COMMON PERONEAL NERVE DYSFUNCTION
Common peroneal nerve dysfunction is damage to
the peroneal nerve leading to loss of movement or
sensation in the foot and leg.
Damage to the nerve destroys the myelin sheath
that covers the axon (branch of the
nerve cell). Or it may destroy the
whole nerve cell. There is a loss of
feeling, muscle control, muscle tone,
and eventual loss of muscle mass
because the nerves aren't
stimulating the muscles.
Common causes of damage to the peroneal nerve include the
following:
• Trauma or injury to the knee
• Fracture of the fibula (a bone of the lower leg)
• Use of a tight plaster cast (or other long-term constriction) of the
lower leg
• Crossing the legs regularly
• Regularly wearing high boots
• Pressure to the knee from positions during deep sleep or coma
• Injury during knee surgery or from being placed in an awkward
position during anesthesia.
Common perineal nerve injury is more common in people:
• Who are very thin (for example, from anorexia nervosa)
• Who have conditions such as diabetic neuropathy or
polyarteritis nodosa
• Who are exposed to certain toxins that can damage the
common peroneal nerve
Charcot-Marie-Tooth disease is an inherited disorder that affects all
of the nerves. Perineal nerve dysfunction occurs early in this
disorder.
Symptoms
• Decreased sensation, numbness, or tingling in
the top of the foot or the outer part of the upper or
lower leg
• Foot that drops (unable to hold the foot straight
across)
• "Slapping" gait (walking pattern in which each
step makes a slapping noise)
• Toes drag while walking
• Walking problems
• Weakness of the ankles or feet
Exams and Tests
Examination of the legs may show:
• Loss of muscle control in the legs (usually the
lower legs) and feet
• Atrophy of the foot or leg muscles
• Difficulty lifting up the foot and toes and making
toe-out movements.
Muscle biopsy or a nerve biopsy may confirm
the disorder, but they are rarely needed.
Tests of nerve activity include:
• Electromyography (EMG, a test of electrical
activity in muscles)
• Nerve conduction tests
• MRI
What other tests are done depend on the
suspected cause of nerve dysfunction, and the
person's symptoms and how they developed.
Tests may include blood tests, x-rays and scans.
TIBIAL NERVE DYSFUNCTION
Tibial nerve dysfunction is a loss of movement or sensation
in the foot from damage to the tibial nerve.
Causes
Tibial nerve dysfunction is an unusual form of peripheral
neuropathy. It occurs when there is damage to the tibial
nerve, one of the lower branches of the sciatic nerve of the
leg. The tibial nerve supplies movement and sensation to the
calf and foot muscles.
The usual causes are:
• Direct trauma
• Pressure on the nerve for a long period of time
• Pressure on the nerve from nearby body
structures
Entrapment createes pressure on the nerve where it
passes through a narrow structure.
The tibial nerve is often injured by pressure from a
ligament on the inner part of the ankle. Injury or
disease of structures near the knee may also
damage the tibial nerve. The tibial nerve may also be
affected by diseases that damage many nerves, such
as diabetes.
In some cases, no cause can be found.
Symptoms
• Sensation changes in the bottom of the
foot and toes
• Burning sensation
• Numbness, tingling, or other abnormal
sensations
• Pain
• Weakness of foot muscles
• Weakness of the toes or ankle
Exams and Tests
An examination of the legs will be done to diagnose tibial
nerve dysfunction. The health care provider will also take
a medical history.
Signs include:
• Inability to curl the toes, push the foot down, or twist
the ankle inward
• Weakness
In severe cases, the foot muscles may become very
weak and the foot may be deformed.
Tests for tibial nerve dysfunction may include:
• EMG (a recording of electrical activity in muscles)
• Nerve biopsy
• Nerve conduction tests (recording of electrical activity
along the nerve)
Tests may also include blood tests, x-rays, or scans.
Varicose Veins
Varicose veins are dilated,
tortuous, elongated superficial
veins that are usually seen in the
legs.
There are three types of veins,
superficial veins that are just
beneath the surface of the skin,
deep veins that are large blood
vessels found deep inside
muscles, and perforator veins
that connect the superficial veins
to the deep veins. The superficial
veins are the blood vessels most
often affected by varicose veins
and are the veins seen by eye
when the varicose condition has
developed.
Causes and symptoms
The predisposing causes of varicose veins are multiple,
and lifestyle and hormonal factors play a role. Some
families seem to have a higher incidence of varicose
veins, indicating that there may be a genetic component
to this disease. Varicose veins are progressive; as one
section of the veins weakens, it causes increased
pressure on adjacent sections of veins. These sections
often develop varicosities. Varicose veins can appear
following pregnancy, thrombophlebitis, congenital blood
vessel weakness, or obesity, but is not limited to these
conditions.
Edema of the surrounding tissue, ankles, and calves, is
not usually a complication of primary (superficial) varicose
veins and, when seen, usually indicates that the deep
veins may have varicosities or clots.
Diagnosis
Varicose veins can usually be seen. In
cases where varicose veins are
suspected, but can not be seen, a
physician may frequently detect them
by palpation (pressing with the
fingers). X rays or ultrasound
tests can detect varicose veins
in the deep and perforator
veins and rule out blood clots
in the deep veins.
Treatment
Treatment falls into two classes; relief of symptoms
and removal of the affected veins.
Symptom relief includes such measures as wearing
support stockings, which compress the veins and
hold them in place. Other measures are sitting down,
using a footstool when sitting, avoiding standing for
long periods of time, and raising the legs whenever
possible. Exercise such as walking, biking, and
swimming, is beneficial. When the legs are active,
the leg muscles help pump the blood in the veins.
These measures reduce symptoms, but do not stop
the disease.
Surgery is used to remove varicose veins from the body. It is recommended
for varicose veins that are causing pain or are very unsightly, and when
hemorrhaging or recurrent thrombosis appear. Surgery involves making an
incision through the skin at both ends of the section of vein being removed. A
flexible wire is inserted through one end and extended to the other. The wire is
then withdrawn, pulling the vein out with it. This is called "stripping" and is the
most common method to remove superficial varicose veins. As long as the
deeper veins are still functioning properly, a person can live without some of
the superficial veins. Because of this, stripped varicose veins are not
replaced.
Amputation
-surgical removal of limb or distal part of
the limb through a bone or multiple
bones.
-removal of the peripheral part of any
organ.
The verb “Amputare” was employed to cutting off the hands
of criminals.
Classification of amputation:
1) In terms of:
- Amputation of the primary indications, by the
provision of emergency surgical care at an early
stage – before the development of clinical signs
of infection;
- Produce a secondary amputation, when
conservative measures and surgical treatment
are ineffective; Amputation of the secondary
indications is performed in any period of
treatment with the development of life-threatening
complications of the patient;
- Re-amputation is produce after unsatisfactory
results of previously made limb truncations, with
evil cults, preventing the prosthesis.
2) In the form of soft tissue dissection:
- Circular way, when the line of cut is
perpendicular to the axis of the limb;
- quilt, when cut is through the soft tissue as
one or several flaps (one-or more quilt)
(Loudhema way);
- Amputation of a cuff of skin (the way of
Petit);
- Oval or elliptical way in which an incision
made in the form of an ellipse, which is
located obliquely to the axis of the limb.
3) By the method of treatment of bone:
- Subperiostal – a plastic method in which the bone is
covered with sawdust scraps from the deleted part of the
periosteum;
- Aperiostal – a way of amputation for adults, in which over
4cm is bare bones. In this method of crossing the
periosteum with a scalpel and shift the rasp farabeuf distally
over a distance at least 0.5 cm, and sawing the bones are at
a distance of 2-3 mm distal to the proximal edge of the flat
periosteum;
- Periostal – a cut through the periosteum distal to the level
of cutting the bone and retard proximally to further conceal
its bone sawdust. The method is applicable only in the
pediatric surgery as a result of good elasticity of the
periosteum for children and for adults such operation leads
to damage of the periosteum, leads to its ossification with
the formation of osteophytes, which causes the formation of
a vicious stump..
Peripheral Vascular Disease
After 12 months
Malignant Tumor
Disarticulation – a surgical operation:
amputation of a limb or the whole of its distal part
and cut through the gap in the joint.
Puncture of joints are used for diagnostic and therapeutic
purposes. Produced diagnostic puncture with needles of different
diameters. Sometimes, when the diagnostic puncture in the joint
cavity injected contrast solution or the air that allows the picture to
determine the condition of bones, cartilage and joints capsules.
After anesthesia of the skin the needle is usually introduced
through the skin with an offset to prevent the formation of a
through channel that reports the joint cavity with the external
environment. The contents of the joint cavity is taken on
bacteriological analysis. The rapid introduction of even a large
needle is usually painless. In most cases, a needle is injected
through the previously anesthetized area of the skin on the
extensor surfaces of the joint, where there are no major blood
vessels and nerves. Diagnostic puncture can be converted into
therapeutic: After removal of the inflammatory exudate in the joint
cavity of novocaine is injected antibiotic. To do this without
removing the needle should be replaced with a syringe connected
to a needle through the rubber tube.
Puncture of the shoulder joint
This operation is carried out in the patient
lying on the healthy side or sitting. Puncture
of the shoulder joint can be made from the
front, outside and behind. In the front
shoulder joint puncture, guided by the
coracoid process, which is palpable on 3 sm
down from the acromial end of clavicle.
The needle is injected directly under the
process and the conduct depth of 3-4 cm
between the it and the head of the humerus.
At the puncture a needle is injected outside
the joint down to the most convex part of the
acromial process of the frontal plane through
the thickness of the deltoid muscle. At
puncture the shoulder joint behind the
needle injected from the acromial process
down, between the rear edge of the deltoid
muscle and the lower edge of the
supraspinatus muscle perpendicular to a
depth of 4-5 cm.
Puncture of the elbow
This operation Produced the
back or the back and outside in
the patient in the healthy side or
sitting. Behind the puncture is
carried out at arm bent at the
elbow at an angle of 135 °; is
injected a needle on the tip of
the olecranon and directed
forward. Behind the outside of a
needle is injected from the
lateral epicondyle down the
humerus, and laterally by the
olecranon of ulna and penetrate
into the joint immediately above
the radial head.
Puncture of the wrist joint
In the pronated wrist with a needle
is injected beam rear side at the
intersection of the line connecting
the styloid process, with the line,
which is a continuation of the
metacarpal bone II.
Puncture of the hip joint
Hip joint is often puncture in the front
of the patient on his back. The needle
is injected strictly in the
anteroposterior direction to a point
located in the middle of a line drawn
from the apex of the greater trochanter
to the femoral border between the
inner and middle thirds of the inguinal
ligament. Puncture Produced palpable
pulse outwards from the femoral artery
at the inner edge of the sartorius
muscle. At the puncture a needle is
injected outside the joint above the tip
of the greater trochanter in the coronal
plane on a slightly abstracted and
medially rotated limbs.
Puncture of the knee
Produce a puncture at the bottom or
top of the patella, departing from it on
the 1-2 cm above the outside if
puncture, a needle is directed
downwards and inwards between the
rear surface of the patella and the
femoral epiphysis.
Puncture of the ankle
This operation Produced the
front, better in external ankle.
The needle is injected
perpendicularly to the skin in
between the talus and the ankle.
The point of puncture is located
on the top 2 cm above the
ankle, 1 cm anteriorly and
medially from it. At have a
puncture a needle is injected
inside the ankle to a point
situated 1 cm above the top of
the ankle and at 2 cm outward
from its inner surface.
Arthroplasty –
Resection arthroplasty with subsequent restoration of
its function. The volume of surgical intervention
depends on the nature of the fusion of articular
surfaces. At fibrous ankylosis of arthroplasty often
consists of surgery artrolizisa – dissection of
adhesions between the articular surfaces. In cases of
bone ankylosis of the osteotomy is performed, and
the mating bones give a congruent shape. The
success of the arthroplasty depends on the quality
cushioning material that prevents the re-fusion of the
newly formed joint surfaces. As the pads were tested
many biological and alloplastic materials, but still
have not managed to pick up a full-fledged
replacement for a living cartilage.
Total Hip Arthroplasty
x-ray image of total knee arthroplasty
Total ankle
arthroplasty
Shoulder arthroplasty.
Total Elbow
Arthroplasty
Osteosynthesis –
a surgical repositioning of bone fragments with
different fixation designs that provide long-term
elimination of their mobility. The purpose of
osteosynthesis – providing a stable fixation of bone
fragments in the correct position while preserving
the functional axis of the segment, the stabilization
of the fracture zone until the seam. The method is
one of the key in the treatment of unstable
fractures of long bones, and, often, the only
possible one for intra-articular fractures in violation
of the integrity of the articular surface. As the
clamps are typically used pins, nails, screws, bolts,
pins, etc., made of materials with biological,
chemical, and physical inactivity.
There are two main types of osteosynthesis –
osteosynthesis, which connect the various bone
fragments latches located in the zone of fracture,
and the external percutaneous fixation when bone
fragments are connected by a compression-
distraction apparatus. Immersion osteosynthesis
based on the location of striker relative to bone is
intraosseous (intramedullary), and extramedullary
transosseus. There are also hybrid forms of
osteosynthesis: intraosseously-extramedullary,
extramedullary, or transosseous-intraosseously
transosseous-such that uses metallic and other
construction.
Intraosseous osteosynthesis performed open,
closed and semi-open method.
Depending on the strength of the connection of
fragments distinguish stable osteosynthesis, if
there is no need for additional fixation, and
unstable osteosynthesis, if the bone fragments
after the connection between them remains the
mobility and requires additional external
fixation, such as plaster cast.
Minimally Invasive Plate Osteosynthesis for Open
Fractures of the Proximal Tibia
Minimally invasive plate osteosynthesis of distal
tibial fractures: a comparison of medial and lateral
plating.
X-ray of osteosynthesis by
screws and plates and
screws on a femur neck.
Frontal x-ray of the left
hip.
Osteosynthesis and bone union of the
osteotomy site at the middle third of Plain radiography after the first
the ulna. osteosynthesis. Osteosynthesis was
applied to the distal radius fracture
using a volar locking plate (A: frontal
view, B: lateral view).
Single-Stage Osteosynthesis and
Revision Arthroplasty of a
Periprosthetic Ulnar Fracture.
Minimally Invasive and
Conventional Plate
Osteosynthesis for
Midshaft Clavicle
Fractures
