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16.05.2005 Версия для печати

Травмы колена

Введение

Факт - травмы нижней части ноги всегда были проблемой горнолыжников. С самого начала переломы костей нижней части ноги (голени и малоберцовой кости) были обычным явлением, так как крутящие силы появляющиеся при падении беспрепятственно передавались от лыжи. Последующее развитие отстегивающихся креплений стало очень успешным путем уменьшения таких переломов, но, к сожалению, такие крепления не повлияли на защиту колена. Травмы этого сустава, его связок, менисков и костей в настоящее время составляет приблизительно 30-40 % всех травм в горных лыжах.

Хотя фокус этой статьи - травмы колена, встречающиеся в горных лыжах, я знаю, что многие найдут интересную для них информацию о травмах колена. Я надеюсь, что эта статья станет для тебя полезной. Я всегда рад получить твое мнение на сайте или по e-mail, если у тебя есть какие-нибудь предложения о том, как улучшить эту статью пиши мне.

В Шотландии травмы колена происходят с частотой 1.13 травм на 1000 дней катания, то есть для каждых 1000 лыжников на горе в любой день в среднем более одного человека травмирует колено. Появление карвинговых ("с боковым вырезом") лыж, привело к улучшению характеристик поворота по сравнению с традиционными лыжами, и привело к увеличению количества травм колена. Это видно по некоторым горнолыжным командам, когда они начали использовать такие лыжи в начале 1990х. Риск получения травмы при использовании карвинговых лыж в настоящее время, похоже, уменьшился – наверное, это связано с тем, что лыжники, катавшиеся на традиционных лыжах, привыкли к карвинговым лыжам, да и лыжи улучшили свои характеристики. Начинающим лыжникам, которые катались только на карвинговых лыжах (не имевшим опыта катания на других видах лыж) не приходится адаптироваться. Хотя прогноз оценки травмоопасности хорош, некоторые из них могут привести к серьезному функциональному ограничению и даже могут закрыть для некоторых этот вид спорта. Точный диагноз совместно с соответствующим обследованием и лечением очень существенно при восстановлении лыжника от таких травм насколько возможно быстрее.

Большинство травм колена среди горнолыжников - повреждение связок колена, особенно внутренней боковой связки. Как и в случае с другими растяжениями связок, эта травма делится на три степени в зависимости от степени повреждения и связанной с этим ослаблением связки. Ослабление определяется попыткой выпрямления - по очевидным причинам поначалу это нельзя сделать сразу, так как врач может заработать синяк от пациента. Как только боль ослабла (обычно 5-7 дней) можно произвести повторный тест.

1 степень - Нет слабости в связке при нагрузке. Несколько волокон связки порвались, если вообще порвались.

2 степень - Небольшая слабость связки, но есть определенная конечная тока. Некоторые, но не все, волокна связки порвались.

3 степень - Полная гибкость связки. Все волокна порвались.

Нижеприведенные признаки говорят о серьезной травме колена - как можно быстрее к доктору!

  • Очевидная деформация колена
  • Невозможно опереться на пострадавшую ногу
  • Большая опухоль в течение двух часов после травмы
  • Невозможность полностью выпрямить колено ("запертое колено")
  • Резкая чувствительность при нажатии на определенную область

Легкая опухоль обычно неизбежна почти при всех травмах колена, кроме самых незначительных, обычно проявляющаяся в течение двадцати четырех часов после травмы. Появление серьезной опухоли (т.е. колено выглядит как воздушный шар!) в течение первых суток после травмы говорит о том, что, скорее всего, появился гемартроз (кровотечение в коленном суставе) что приблизительно в 75% случаев говорит о повреждении передней крестообразной связки. Во всех случаях гемартроза необходимо обратиться к хирургу-ортопеду для точной диагностики и возможного выпуска крови из сустава. Это должно производиться в стерильных условиях. Не пытайся этого делать дома...

Точное описание несчастного случая с честной оценкой уровня катания на лыжах почти во всех случаях подскажет правильный диагноз. Направление, в котором двигалась нога при падении, подскажет, какие структуры могли пострадать и скорость лыжника влияет на степень травмы. Начинающие лыжники сначала обучаются "плугу". Это создает напряжение средних вспомогательных связок и требует сильных четырехглавых мышц, чтобы поворачивать и поддерживать стабильность, особенно в широкой стойке, которая более неустойчива (фото справа). При такой широкой постановке лыж трудно приложить всю мускульную силу вниз каждой ноги и вследствие чего легко потерять контроль над лыжей или обеими и лыжи обычно заставляют нижнюю ногу провернуться наружу относительно бедра - врачи дали этому движению название "вальгусная деформация". Когда нижняя нога поворачивается внутрь бедра, называется "варусная деформация сустава" но это встречается реже, чем вальгусная.

С увеличением способности лыжники могут удерживать ноги параллельно, что увеличивает эффективность поворотов и позволяет развивать большие скорости. И хотя это намного приятнее, чем борьба с плугом, большие скорости могут привести к более тяжелым травмам в кратковременный момент несчастного случая просто, потому что силы прилагаются через сустав выше.

В середине располагаются так называющиеся "стем" повороты - частично плуг, частично параллельный поворот - удел многих среднего уровня лыжников отчаявшихся научиться выполнять полностью параллельные повороты. Если ты на этом уровне, опасность в том чтобы кататься слишком быстро для твоей способности торможения и / или кататься со склонов выше твоих способностей.

Общее лечение всех острых травм колена

  • Защита, отдых, лед, сжатие (см. ниже) и подъем.
  • Шерсть + давящая повязка (Роберт-Джонс) приложенная как минимум на первые 24 часа - потом заменяется на шину.
  • Менее серьезные травмы требуют меньшую степень поддержки (то есть хватит давящей повязки).
  • Костыли, если потребуются.
  • Не стероидные противовоспалительные медикаменты, если не противопоказано (обратись к фармацевту за консультацией). Это необходимо продолжать не менее 5 дней (даже если состояние колена улучшилось).
  • Выполнение упражнений для четырехглавой мышцы. Четырехглавые мышцы - мышцы бедра и очень важно после любой травмы колена поддерживать их нагрузку. Ты поразишься, насколько быстро они теряют свою силу, когда не используются и это плохо для коленного сустава.
  • Физиотерапевтическое лечение - как можно быстрее - часть из этих процедур поддерживают четырехглавую мышцу в тонусе.
  • Оценка стабильность связки, как только острая боль утихла, используя, если потребуется, для сравнения непострадавшую сторону для сравнения.

Растяжение средних вспомогательных связок

Охват: Самая распространенная травма в горных лыжах, составляет 20-25% всех травм. Наиболее часто встречается у начинающих и нижнего среднего уровня лыжников.

Причина: Получившие травму обычно в "плуге", коленный сустав в вальгусной позиции (нижняя часть ноги отклонена относительно бедра). Травма получается в результате чрезмерной вальгусной силы применяемой к коленному суставу, или в результате падения, лыжи перекрещиваются, или плуг расширяется. У более продвинутых лыжников обычно происходит в результате неожиданной "ловли канта", которая неожиданно бросает лыжу (и нижнюю часть ноги прикрепленную к ней) наружу.

Диагностика: предварительный диагноз обычно определяется по описанию падения. При проведении диагностики ощущается болезненность над средней вспомогательной связкой и боль при нагрузке весом. Наличие гемартроза предполагается при третьей степени, связанное с повреждением передних крестообразных связок и / или травмой костяных структур колена.

Оценка: В острой фазе, боль обычно мешает точной оценке стабильность связки. Когда возможно, оценка должна проводит ь ся при помощи вальгусного напряжения при согнутом на 30 градусов колене и ногой развернутой внутрь (см. рисунок ниже).

Обследование: Обычно нет необходимости, но рентгенограмма определит наличие травмы кости, а магниторезонансное сканирование определит повреждение других мягких тканей (например, передней крестообразной связки / миниска).

Лечение: При первой и второй степени растяжении связок необходимо наложить растяжку пока боль и опухоль не спадет. При третьей степени может потребоваться хирургическое вмешательство или наложение гипса.

Предотвращение: Предсезонные нагрузки четырехглавой мышцы, правильный уход за креплениями и правильные настройки отсоединения лыж. Избегание широкого плуга, который по определению нестабилен. Начинающим рекомендуется падение, если появляется его вероятность, чем попытки противостоять ему, что может привести к большему ущербу.

Растяжение передних крестообразных связок

Охват: Составляет 10-15% всех горнолыжных травм (по некоторым исследованиям даже больше). Обычно диагностируется поздно, если вообще диагностируется. Обычно связано с травмами других структур колена (например, средних вспомогательных связок и/или миниска).

Причина: Американское исследование выделило два основных механизма приводящих к повреждению передних крестообразных связок у горнолыжников. Они были названы "призрачная ступня" и "вызванный ботинком" сценарии. Первый механизм срабатывает когда хвост нижней по склону лыжи ("призрачная ступня") в комбинации с жесткой настройкой задника лыжного ботинка участвуют как рычаг, применяемый к уникальной крутящей и сгибающей силе через коленный сустав. Анализ видеосъемок более чем 14,000 лыжных травм определил типичный профиль, характеризующий этот механизм травмы.

Профиль призрачной ступни

  1. Верхняя по склону рука сзади
  2. Лыжник вне баланса на зад
  3. Бедра ниже коленей
  4. Верхняя по склону лыжа не нагружена
  5. Вес на внутреннем канте хвоста нижней по склону лыжи
  6. Верхняя часть тела развернута в сторону нижней по склону лыжи

Когда все шесть признаков призрачной ступни присутствуют, вероятность травмы передней крестообразной связки чрезвычайно высока. Следующие ситуации могут предрасполагать к такому сценарию:

а) Попытка встать при продолжающемся скольжении после падения.
б) Попытка восстановиться после потери баланса.
в) Попытка сесть после потери контроля.

Вызванный ботинком механизм происходит, когда лыжник вне баланса назад во время попытки прыжка. Инстинктивно ноги лыжника полностью выпрямляются. В результате лыжник приземляется на хвост лыж, что вызывает лыжными ботинками силу, направленную на икру, которая проходит через большую берцовую кость над бедром и рвет переднюю крестообразную связку.

Сейчас найден третий механизм, когда неподвижный лыжник подвергается удару в нижнюю часть ноги - это также прилагает внезапное давление на зад игры, вынуждая голень сместиться вперед, что в результате приводит к травме.

Диагностика: Часто пострадавший описывает, что почувствовал или услышал "щелчок" или "треск" внизу колена. Гемартроз обычно развивается в течение часа.

Обследование: Магниторезонансное сканирование рентгенограмма для определения повреждения костей, мягких тканей и подтверждения диагностики.

Лечение: Спорное! В Англии основным лечением является консервативное с интенсивной физиотерапией направленной на усиление мышц, чтобы стабилизировать сустав. В США и Европе, раннее артроскопическое восстановление связки. В основном соглашайся, если хочешь продолжать кататься на среднем хорошем уровне или выше. Однако если твое колено стабильно после консервативного лечения этого можно избежать. Другие используют поддержку для дополнительной защиты (смотри ниже).

Предотвращение: Учись распознавать потенциально опасные ситуации. В основном, всегда старайся держать руки впереди, ноги вместе и руки над лыжами. Программа предохранения от травм передней крестообразной связки предлагаемая Эттлингером показывает снижение количества травм на 62% (смотри ссылку ниже). Сайт Карла Эттлингера можно найти по этому адресу.

Избегание высокой вероятности травмы передней крестообразной связки

1. Не распрямляй полностью ноги при падении. Держи колени согнутыми.

2. Не пытайся встать пока не остановишь скольжение. Если ты лежишь - оставайся лежать.

3. Не приземляйся на руки. Держи руки вверху и впереди.

4. Не прыгай, пока не знаешь, куда и как приземляться. Приземляйся на обе лыжи и держи колени согнутыми.

Перелом большеберцовой кости

Охват: Приблизительно 1 % всех лыжных травм. Обычно затрагивает пожилых, более опытных лыжников.

Причина: Серьезная вальгусная нагрузка часто с силой сжатия, например в результате плохого приземления после прыжка.

Диагностика: Гемартроз обычное явление. Может присутствовать ушиб и или ссадина над боковой стороной сустава и вальгусная деформация колена.

Обследование: Обычно видно на обычных рентгенограммах. Может потребоваться томограмма для точного определения угла смещения и пострадавшей поверхности.

Лечение: Если перелом смещен более чем на 4 мм, тогда предлагается операция для восстановления позиции. Часто эти травмы происходят на больших скоростях и в связи с этим происходят травмы других мягких тканей - особенно передней крестообразной связки и средней вспомогательной связки, что требует хирургического вмешательства.

Предотвращение: Избегать высоких прыжков и последовательных сильных ударов.

Травмы мениска

Охват: Составляет 5-10% всех лыжных травм, часто одновременно с повреждением других структур. Обычно затрагивает боковой мениск из-за скручивания в колене.

Причина: Крутящая нагрузка, примененная на согнутую, нагруженную ногу. Обычно в результате ловли канта на скорости.

Диагностика: Серьезная боль и затрудненная нагрузка весом, но может быть маленькая опухоль. Очевидная болезненность, особенно в последние несколько градусов распрямления колена. Может представляться как "запертое колено" когда оборванный фрагмент мениска физически препятствует полному распрямлению сустава. Тест на разрыв мениска включает тест МакМюррея (смотри слева) и тест на сжатие Апли.

Обследование: Снимки могут потребоваться для исключения других травм.

Лечение: Запертое колено требует ранней артроскопии и восстановления. Остальные отдельные разрывы можно лечить консервативно с надеждой на выздоровление.

Ссылки

Paletta GA and Warren RF. Knee Injuries and Alpine Skiing: Treatment and Rehabilitation. Sports Med 1994 17(6) 411-423.

Ettlinger CF, Johnson RJ and Shealy JE. A Method to Help Reduce the Risk of Serious Knee Sprains Incurred in Alpine Skiing. Am J Sports Med 1995 23(5) 531-537

Langran M, Jachacy GB and MacNeill A. Ski Injuries in Scotland: A Review of Statistics from Cairngorm Ski Area, Winter 1993/4 Scot Med J 41(6) 169-172

Johnson RJ and Ettlinger CF. Alpine Ski Injuries: Changes Through the Years. Clin Sports Med 1982 1(2) 181-197

Mona D ACL Reconstruction and Rehabilitation: A Protocol of Accelerated Rehabilitation. Department of Sports Trauma, Lugano, Switzerland. Presented at 13th International Congress on Ski Trauma and Skiing Safety, Cervinia, Italy. May 1999.

Johnson RJ, Ettlinger CF, Shealy JE and Meader C. Impact of Super Sidecut Skis on the Epidemiology of Skiing Injuries. Sportsverl. Sportschad 1997 11 150-152

Langran M, Selvaraj S. Snow Sports Injuries in Scotland. A case-control study. Br. J Sports Med. 35:135-140, 2002

Miller SL, Gladstone JN. Graft selection in anterior cruciate ligament reconstruction. Orthop Clin North Am 2002 Oct;33(4):675-83

Rossi MJ, Lubowitz JH, Guttmann D. The skier's knee. Arthroscopy 2003 Jan;19(1):75-84

Автор: Dr Mike Langran.
Источник: www.ski-injury.com.
Перевод: k0ry.

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[27.04.2011 / 09:51]

спасибо
[21.07.2010 / 07:56]

спасибо. такой материал трудно найти.
[02.02.2010 / 23:25]

Действительно, статья очень хорошая, даже я , уже достаточно в \"теме\", узнала много интересного. А поскольку сайт mamboo.ru временно недоступен, подскажу, как другим способом получить ответ на вопрос профессора Королева Андрея Вадимовича, лучшего спеца по лыжным травмам и не только, на форуме www.sport-clinic.ru Не сочтите за рекламу, очень хочется помочь людям, а доктор- чудо, я его очень уважаю и нежно люблю.
[24.01.2010 / 15:34]

Просто к сведению: Во вопросам спортивной травмы можно проконсультироваться онлайн в форуме \"Консультация травматолога\" на сайте mamboo.ru, на вопросы отвечает один самых-самых спортивных травматологов Андрей Вадимович Королев.
[11.01.2010 / 14:31]

Отличная статья! Спасибо!
[05.01.2010 / 00:43]

Спасибо большое. Статья нам очень помогла
[17.05.2009 / 19:29]

да уж)) статья полезная))я хоть и не горнолыжница, но по своей иравме тоже много чего узнала.
маша почка
[22.01.2009 / 20:21]

Где ваша печень?
mihail
[18.03.2008 / 07:03]

Диагноз мне поставили американцы: sprained ligaments of the knee (растяжение связок, как я понял). Произошло это 2 месяца назад. Сказали ничего серьезного, часто встречающаяся у лыжников травма. В течение 3-5 недель должно было наступить полное выздоровление. Боль до сих пор не стихает. Часто оступаюсь, как бы не ощущаю опоры в колене. Не доверяю я американцам, по приезду домой обращусь к нашим.
Марина
[10.03.2008 / 01:52]

Да, статься правда очень хорошая и доступно написано. Правда с операциями стоит вначале повременить... У меня перелом большой берцевой кости с отрывом передней крестообразной связки, говорили что срочно нужна операция, а один врач сказал что все обойдется так и случилось... так что консультируйтесь с несколькими врачами. Так что горноложники не отчаивайтесь :)
Lexx2007
[30.09.2007 / 17:32]

Статья очень интересная и познавательная! Кто хочет пообщаться на эту тему! Пишите! e-male:aleksey.vasilev@kos.unimilk.ru
Антон
[14.03.2007 / 21:13]

Отличная статья, пролила мне свет на то, что произошло и что было причиной моей травмы. Начиная от сценария падения и заканчивая назначенной терапией все очень похоже на правду.. Вот только так и не разобрался на рисунке вверху, что называется передней крестовидной связкой которую я оторвал.. Надеюсь что операция действительно позволит и дальше покорять склоны, хотя бы на среднем уровне..

 

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