Fracture of the femur code according to the ICD. Signs, treatment and consequences of a femoral neck fracture

Femoral neck fracture (ICD-10 code – S72.0) is a common pathology encountered in traumatology. It is important to understand that such an injury is considered very serious, especially in old age. Its complications can be very serious. Hip injuries should always be treated immediately and effectively, regardless of the type. Treatment, care, recovery - all this plays an important role.

Today, many methods have been developed for the treatment and restoration of hip injuries that affect the condition of the entire leg. Surgeries, plaster casting, orthosis, exercise therapy - all patients who are treated at home or in hospital encounter some of these methods. Each method plays an important role, as will be discussed below. Each patient must take the doctor’s orders, strictly follow the exercises, exercise therapy and other appointments. But first, it is important to know the causes of injury and the signs that will help identify it.

Causes

In people over 40 years of age, the main reason is high bone fragility, which is caused by osteoporosis. Moreover, in order for an injury to occur, a small traumatic force is needed, even when falling from a height of one’s height while walking.

There are other factors due to which a pathological fracture of the femoral neck can occur at an older age:

• oncology;
• visual impairment;
• excess weight;
• menopause;
• inactive lifestyle;
• diseases of the nervous system that are accompanied by movement disorders;
• starvation, poor nutrition;
• vascular pathologies.

A fall may be one of the causes of a fracture

In young people, the most common causes are falls from great heights, work-related injuries, road accidents, and combat wounds.

Depending on the conditions of the injury and other factors, there are several types of injuries to the femur according to ICD-10. Classification is determined by various factors. For example, there are injuries that differ in level of location. In this regard, the classification includes the following types of femoral neck fractures:

• basiscervical - located at the base of the femoral neck, far removed from the head;
• transcervical - pass through the femoral neck;
• subcapital - located near the head of the femur (a subcapital fracture is the most unfavorable in terms of prognosis).

The more vertical the fracture line is, the less likely there are complications and displacements. The prognosis also depends on the degree and direction of the displacement. The classification of femoral bone injuries also includes types of displacements:

• varus fracture, when the bone head moves inward and downward, the angle between the body and the neck decreases;
• valgus, when the head moves outward and upward, the angle between the body and the neck becomes larger;
• impacted, when one fragment is driven into another, in most cases this injury is also valgus.

Traumatology also distinguishes medial and lateral fractures. The first type is also called intra-articular injuries, they are located above the joint attachment with the hip. Lateral or lateral injuries are located below the attachment of the joint capsule. In this case, patients easily come to their senses if there are no complications. Like all other bone injuries, femoral neck fractures can be open or closed, the difference being whether there is damage to the skin or soft tissue.

Symptoms

Swelling, pain and limitation of movement are the first signs of a fracture

Thanks to the timely identification of signs of injury, it is possible to provide timely assistance, which determines the further development of situations and the presence of complications. Of course, the exact diagnosis in accordance with the ICD-10 code is made by the doctor, but the first steps are taken by those around you. Swelling, pain, limitation of movements - these and other signs together indicate an injury. You can look at them more closely.

Symptoms of a femoral neck fracture:

1. Pain. It is localized in the groin area. When a person tries to make a movement, the pain becomes stronger. How long the pain lasts depends on various factors.
2. External rotation. This means that the broken leg is turned outward, this may not be immediately noticeable, you should pay attention to the foot.
3. Shortening of the limb. If the legs are carefully straightened, the victim will be slightly shorter. It has been noted that shortening of the leg occurs with varus fractures.
4. Stuck heel. The patient is unable to support the injured straightened leg; the heel slides along the surface, but the person is able to bend and straighten the limb.
5. Subcutaneous hematoma. It occurs in the groin area, usually after a few days.

It is easy to distinguish between a closed and an open femoral neck fracture. In the latter case, the skin is damaged, which can cause swelling. There may be bleeding. In these cases, hip injuries may be combined with fractures of other bones.

Treatment

Before the victim is taken to the hospital, where, after examination, he is diagnosed in accordance with ICD-10 and treatment is prescribed (orthosis, plaster, rehabilitation based on exercises and other methods), first aid must be provided.

The victim must be laid on his back and his leg secured with a splint.

The main thing is not to try to give the leg a normal position. The victim cannot sit, he must lie down. This is why you first need to put him on his back. When he is lying down, you need to fix the leg with a splint, and you should grab the hip and knee joints. After immobilization, you need to take the victim to the hospital or wait for the ambulance to arrive, which must be called immediately after the incident. You can give the patient painkillers if they are experiencing severe pain. If the fracture is open and there is bleeding, it should be repaired and an antiseptic bandage applied.

The greatest difficulty is the treatment of a medial type femoral neck fracture. This is explained by local anatomical features and difficulties in immobilization. For medial fractures, surgery is more often used. Surgical methods will be discussed a little later.

It has already been mentioned that in traumatology there are various treatment methods: surgery, orthosis, the use of plaster, and so on. Recovery after fractures is also mandatory: exercises, massage, and so on. A set of methods is used for rehabilitation. During the treatment process, quality patient care is very important. It is important to remember that pain, swelling and other signs may appear during treatment. You need to talk to your doctor about this. When the doctor makes a diagnosis in accordance with ICD-10, treatment tactics are determined. When choosing treatment, the doctor takes into account such an important factor as a medical history of a femoral neck fracture.

One of the methods is an orthosis. Its purpose is to provide stabilization of the hip joint after injury. The orthosis serves as a prevention of osteoporosis after a femoral neck fracture. A hip orthosis can and should be used after joint replacement. It consists of a belt and a leg piece. These elements of the orthosis are fixed using Velcro fasteners. The orthosis is fixed in front and on the inner thigh using such a fastener.

A derotational boot is needed to eliminate outward rotation of the foot

Another method is to use a derotation boot. It is needed to eliminate outward rotation of the foot. However, the derotation boot has a drawback - it makes walking almost impossible. The patient may have difficulty sitting. The use of this method must be justified.

Treatment of an impacted femoral neck fracture is based on the application of a plaster splint. The period of wearing it is from three to four months. At this time, care is important; the patient should not lean on the injured leg. Displaced fractures are treated by wearing a plaster cast. The use of plaster in the treatment of fractures is a traditional method. In this case, a person may experience unpleasant sensations of swelling and pain. The doctor should know about this. The use of plaster usually goes without complications.

If there are no indications for conservative treatment, surgery is performed. At the same time, it cannot be done, but must be done. If the operation is not performed immediately, skeletal traction is first applied. Among the types of surgical intervention, osteosynthesis stands out - connecting fragments with fixing structures. There is also another type - hip replacement, that is, replacement of the head of the bone. After operations, care is important; exercise therapy is also prescribed. Care can be provided by one of the relatives or health workers.

During the treatment process, things do not always go smoothly. You may experience swelling, pain and discomfort. Sometimes swelling and pain are a normal reaction; in any case, you need to tell your doctor everything. He can tell the reason and guess how long these sensations will be observed. Much depends, again, on patient care.

To make the consequences of a hip fracture less noticeable, good care is important. In traumatology, recovery from injury includes the use of methods such as exercise therapy, exercises, and wearing orthopedic shoes subsequently. The doctor will tell you how many and how to do them, depending on the patient’s condition. The methods are used in combination.

Exercises should be done carefully. It is best if exercise therapy is carried out by a specialist. Depending on the situation, exercises are done shortly after applying the bandage or surgery.

Each method, be it physical therapy or other exercises, is included in quality patient care. How long it will last is determined individually. If the patient strictly follows the instructions, takes a responsible attitude towards performing exercises, exercise therapy, etc. his condition will improve quickly.

According to the ICD 10 classification, which is used by doctors all over the world, a violation of the integrity of the hip bone is indicated by code S 72. In addition, it distributes the injury into several more subsections that help identify the type and severity of the fracture.

ICD 10 subparagraphs and injury codes:

• S0 – damage to the femoral neck.
• S1 – pertrochanteric.
• 2 – subtrochanteric.
• 3 – diaphysis fracture
• S4 – fracture of the lower part of the bone.
• S7 – multiple fracture.
• S8 – fracture in other parts of the bone.
• S9 – fracture of unspecified location.

Etiology

In many cases, a fracture of the femur or pelvic bones occurs in elderly people who have slipped or fallen from a height on their leg. Men and women over 60 years of age, whose bodies are susceptible to age-related changes, have a high chance of injury.

Joints weaken and lose their ability to withstand loads and body weight, and fragile bones are easily cracked and broken even after light blows.

People at a young age often suffer fractures after car accidents, falls from great heights, or excessive stress while playing sports.

High-risk group:

• The most susceptible hips to injury are women in old age (every 4 cases), this is due to the anatomical feature of the bone, which in some areas is thinner than in men. Also, with the onset of menopause, against the background of a sharp change in hormonal balance, a woman is actively washed out of calcium, and her bones become fragile.
• History of diabetes, arthritis, osteoporosis, multiple sclerosis, etc.
• Blind and poorly sighted.
• Genetic predisposition to bone pathologies.
• People being treated with diuretics and anticoagulants.
• Alcoholics and drug addicts.

Symptoms and complications

Of course, like any other injury, a hip fracture (ICD-10) is characterized by the presence of pain, which intensifies with movement. However, there have been cases when an injury was left without proper attention because the patient did not seek medical help.

It’s hard to imagine, but the patients felt virtually no pain, and the joint remained mobile. Such patients with a fracture of the femoral neck of the leg could not even imagine that the injury was so serious and thought that they had an ordinary bruise.

However, there are special signs of damage, from which one can understand what exactly happened to the hip bone:

1. A hematoma becomes noticeable in the joint area, since a broken bone can damage one of the vessels, causing internal hemorrhage;
2. The damaged leg is visually shortened, this occurs due to a shift in the bone and a spasm in the muscles that automatically pull the limb towards the pelvis;
3. The heel in the injured limb is turned outward, this is especially clearly visible in contrast with the healthy leg;
4. Sometimes, there is a restriction of movements, up to a complete loss of the ability to move.

Until recently, at the end of the last century, medicine was not yet at such a high level, and most elderly people with a hip fracture were doomed, since the body, due to age, could no longer cope with complications after such a serious injury:

• development of thrombosis;
• bedsores;
• necrosis of bone and muscle tissue;
• pneumonia;
• atrophy of the periarticular muscles;
• depression;
• possible death in elderly patients.

The femur can be cracked or fractured in different areas - proximal (the part near the hip joint), distal (closer to the knee joint) and in the diaphysis (the middle part of the bone).

Each type of injury manifests itself differently and also requires a different approach in terms of treatment and rehabilitation.

What are the types of collum femoris fractures?

Each type of fracture has its own characteristics and clinical symptoms. The most dangerous and complex is an impacted intra-articular fracture, which, if not treated correctly, can become complicated and require urgent surgical intervention.

Impacted fracture

Fracture of the distal part

This is a relatively minor injury compared to a fracture of the neck, head or diaphysis. The pain is less severe, shock rarely occurs. The victim has pathological mobility of the lower leg, as the integrity of the knee joint is compromised.

How long does it take for a person to recover after a collum femoris fracture?

The injury progresses individually for each patient, so it is impossible to set clear time frames for recovery after it. In many ways, the rehabilitation period depends on the severity of the injury, the location of the fracture, the presence of complications, and the age of the patient.

According to medical statistics, the average rehabilitation period is at least 5-6 months, only after this period can the victim attempt to fully stand on the injured limb.

The instructions for the rehabilitation period are to carry out the following actions:

• Approximately 3 days after applying the plaster cast, they begin to perform a light massage of the lumbar area of ​​the patient. Then they move on to the uninjured limb, and only after a week can you begin to gently stroke and lightly rub the injured leg. All movements must be smooth and careful.

Attention! During the massage, you should not apply intense pressure or intense rubbing - this can lead to internal bleeding, detachment of blood clots and their subsequent entry into the lumen of large blood vessels, which causes their blockage.

• 3-4 weeks after the cast is removed, the patient begins to be carefully helped to move the knee - bend and straighten. All actions must be gradual. Another 1 month after removing the cast, the patient can attempt to sit down; of course, this should be done under the supervision of a doctor.
• 3-3.5 months after the injury, the patient is allowed to get out of bed and walk, leaning on a crutch. In this case, all support should be on the uninjured limb, and you can only lightly step on the sore leg with your toe.

With each passing month, if rehabilitation proceeds without complications, the load on the injured limb increases and after six months the patient can try to stand on both legs. In the video in this article, the specialist explains in detail how the rehabilitation period goes after and how the patient should behave so that the recovery is correct and painless.

Diaphyseal fracture

In this part, the bone is surrounded by a muscular apparatus, and large blood vessels and nerve fibers pass near it. Any fracture in the middle part is often accompanied by massive blood loss and shock.

In most cases, the patient experiences displacement of fragments due to the influence of muscle contractions. And it is the fragments that injure blood vessels, muscles and nerves.

A fracture of the diaphysis occurs with severe pain, it is more pronounced than with injury to other parts, and against its background pain shock develops. The thigh circumference increases sharply (displacement of bones and muscles, formation of edema and massive hematoma).

Upon examination, a specific sign of “pathological mobility of the hip” can be identified; during palpation, crepitus of bone fragments can be heard. If the victim has thin muscles and a layer of fatty tissue, the fragments can tear the skin, and the fracture will be called an open fracture. In this situation there is a high degree of infection.

We provide first aid

If you suspect a fracture of the collum femoris, the victim must urgently call an ambulance and leave him motionless until the medical team arrives.

Sometimes it happens that the arrival of doctors is impossible and it is necessary to independently transport the patient to the emergency room; in such a situation, certain transportation rules should be followed:

• lay the victim on his back;
• in case of severe unbearable pain, the victim should be given ibuprofen-based analgesics - this will make it easier to endure transportation and serve as a prevention of painful shock;
• the injured limb should be immobilized as much as possible - for this, the limb is fixed using a splint, it can even be made from improvised material (boards, plywood, slats), and all joints of the injured limb should be fixed, and not just the hip;

Important! The splint must be applied correctly. To do this, it begins in the groin area on the inside of the thigh and ends at the heel. Fix the splint with a bandage in the groin, knee and heel area.

If a person has suffered a femur injury, it is very important to provide him with first aid before the ambulance arrives, since future treatment and rehabilitation largely depend on it. Emergency aid algorithm:

1. To begin with, the victim is brought out of the state of shock.
2. If there is bleeding, it must be stopped.
3. Administer painkillers.
4. Immobilize the limb using a splint. Any available means (boards, long branches, pipes, etc.) are suitable for this. From the outer part of the thigh, the splint is adjusted to the entire side of the body (from the foot to the armpit), from the inner part (from the foot to the groin).

Exercises

Performing a special set of physical exercises during the rehabilitation period is a prerequisite for a successful outcome of injury and serves as an excellent prevention of many complications. In addition, physical exercise helps to avoid muscle atrophy and promotes the speedy restoration of motor function of the limb.

First, exercise therapy is based on massage, stroking and light kneading of the limb, including the lower back, anterior abdominal wall and healthy limb. Breathing exercises are mandatory.

Skeletal traction

Treatment using the skeletal traction method has a minimum of contraindications and consists of gradual restoration of bone tissue due to rationally selected load and natural movement of debris. The traction process is monitored by the attending physician, so the patient must be on bed rest.

The leg is fixed with a special splint, after which a course of rehabilitation is selected. To ensure that traction occurs gradually and as efficiently as possible, Kirschner wires are used.

After analyzing the nature of the injury and the characteristics of the patient himself, a load is selected that will become a stimulator of traction and recovery. The parameters of the load may vary - for example, for a fracture of the neck, a load of around 2 kilograms is used, and for the body of the hip, starting from 6 kilograms.

After the installation of the knitting needles, the patient is limited in movement, so he needs to perform special exercises from the exercise therapy complex for the legs, and physiotherapeutic procedures.

Rehabilitation

Rehabilitation is not only about doing exercises and doctor’s instructions. For a successful outcome of an injury, a positive attitude is extremely important, because if the patient is in a state of constant depression and apathy, then recovery will proceed more slowly.

It is very important to provide the patient with adequate nutrition, healthy sleep, access to fresh air, and leisure (books, TV) so that he does not feel unwanted, abandoned, and a burden to his family.

Short description

The following subcategories are provided for optional use to further characterize a condition where multiple coding to identify fracture and open wound is not possible or practical; If a fracture is not designated as closed or open, it should be classified as closed: 0 - closed 1 - open

Intertrochanteric fractureTrochanteric fracture

Hip fractures account for 6.4% of all fractures.

Classification Fracture of the proximal femur Isolated fracture of the greater trochanter Fracture of the diaphysis of the femur (upper, middle, lower third) Fractures of the distal femur. Fractures of the proximal femur Medial (cervical) fracture can be valgus and varus Capital fracture (head fracture) Subcapital fracture (at the base of the head) Transcervical (transcervical) or basal fracture Lateral (trochanteric) fracture Intertrochanteric fracture Pertrochanteric fracture Isolated fracture of the lesser trochanter Frequency - 25% total number of femur fractures. Fractures of the femoral neck and trochanteric fractures are observed mainly in women over 60 years of age Causes: indirect injury - a fall on the greater trochanter Clinical picture Pain in the groin area, aggravated by leg movements External rotation of the limb, impossibility of internal rotation Shortening of the limb Pain with axial load (tapping on the heel or in the area of ​​the greater trochanter) Symptom of a “stuck heel” - the patient cannot lift or hold a raised and straightened leg, but bends it at the knee and hip joints so that the heel slides along the support. The diagnosis is confirmed by x-ray examination in two projections. A violation of the integrity of the bone is revealed, as well as additional signs: in varus fractures, the greater trochanter is located above the Roser-Nelaton line; in displaced fractures, the Schumacher line connecting the apex of the greater trochanter with the anterior superior iliac spine passes below the umbilicus. Complications: false joint of the femoral neck, avascular necrosis of the femoral head

The first month of rehabilitation should be carried out under the strict supervision of specialists. When performing physical therapy exercises, the patient should look at how he is feeling and not overexert himself.

List of exercise therapy exercises for hip recovery in the first period:

1. Lying on your back, you need to stretch your arms along your body.
2. The arms are raised up (when inhaling) and lowered down (when exhaling).
3. Sharp jerks of the arms forward and backward (strikes).
4. Exercises for the head (bending forward while trying to touch your chin to your chest).
5. Clench your fingers into a fist as you inhale and unclench your fingers as you exhale.
6. Pull your feet towards you, only your toes on the injured leg.
7. Flexion movements of the knee of the healthy leg.

Second period of exercise therapy:

1. The hands, clasped in the fingers, are placed behind the head, stretched upward and returned back.
2. Performing hand movements that resemble stretching rubber.
3. Extension and flexion of the knee of the healthy leg.

Hip fractures account for 6.4% of all fractures.

Classification

Fracture of the proximal femur Isolated fracture of the greater trochanter Fracture of the diaphysis of the femur (upper, middle, lower third)

Fractures

distal femur.

proximal femur Medial (cervical) fracture can be valgus and varus Capital fracture (head fracture) Subcapital fracture (at the base of the head) Transcervical (transcervical) or basal fracture Lateral (trochanteric) fracture Intertrochanteric fracture Pertrochanteric fracture Isolated fracture of the lesser trochanter

25% of the total

fractures

femur.

femoral necks and trochanters

Celebrated mainly in women over 60 years of age Causes: indirect injury - fall on the greater trochanter

Pain in the groin area, aggravated by leg movements External rotation of the limb, impossibility of internal rotation Shortening of the limb Pain with axial load (tapping on the heel or in the area of ​​the greater trochanter)

“sticky heel” - the patient cannot lift or hold a raised and straightened leg, but bends it at the knee and hip joints so that the heel slides along the support. The diagnosis is confirmed by x-ray examination in two projections. A violation of the integrity of the bone is detected, as well as additional signs: with varus

fractures

The greater trochanter is located above the Roser–Nelaton line, with

with displacement, the Schumacher line connecting the top of the greater trochanter with the anterior superior iliac spine passes below the umbilicus Complications: false joint of the femoral neck, avascular necrosis of the femoral head

Treatment of femoral neck fractures is predominantly surgical - osteosynthesis with a metal pin, threaded rods, endoprosthetics. In the treatment of intertrochanteric and pertrochanteric fractures, skeletal traction, plaster cast and osteosynthesis are used. Prevention of pulmonary complications, bedsores.

Fractures of the femoral shaft Causes: direct trauma

Pathomorphology

fracture

in the upper third of the diaphysis, the proximal fragment moves forward and outward, the distal fragment moves inward and posteriorly; For

fracture

in the middle third there is a characteristic shift along the length

Pain, dysfunction, shortening of the limb, deformity, outward rotation of the foot, pathological mobility

Complications

traumatic shock, fat embolism, significant blood loss

Treatment

Immobilization is used for birth injuries in children; traction according to Shede Skeletal traction for the tibial tuberosity or femoral condyle External or internal osteosynthesis

Surgical treatment

used for open, complicated

If conservative treatment is unsuccessful (soft tissue interposition).

Fractures of the distal femur

Causes

direct injury to the lateral surface of the knee joint, a fall on the knee joint, a fall from a height onto straightened legs

condyles - intra-articular injuries accompanied by hemarthrosis. For supracondylar

the short distal fragment is displaced posteriorly due to traction of the gastrocnemius muscle, which creates a threat of compression or damage to the popliteal artery

swelling, deformation, pain, pathological mobility of fragments. X-ray confirms the diagnosis

Treatment:

For hemarthrosis - puncture of the knee joint

without displacement - plaster cast If fragments are displaced - immediate reposition with skeletal traction, according to indications - osteosynthesis

if conservative methods are ineffective, early prescription of physiotherapy (UHF, magnetic therapy), exercise therapy.

ICD-10 T93. 1 Consequence of a hip fracture S72 Fracture of the femur.

Of all known bone fractures, hip fracture (ICD-10 code) accounts for 5-6%. Diagnosed using MRI, radiography for intra-articular fracture.

Main symptoms: pain, limited hip mobility, deformity and shortening of the affected limb. Methods of therapy: reposition of fragments, fixation with a three-bladed nail (knitting needles). In some cases, patients are prescribed skeletal traction.

Causes of hip fracture

The main causes of hip fracture in young patients:

• swipe;
• falling from height.

In elderly patients:

• light blow;
• falling from a small height;
• a consequence of an unsuccessful stumble due to excessive fragility and fragility of bones, degradation of bone mass in people after 65 years.

The risk group includes:

• premenopausal women;
• elderly patients suffering from osteoporosis, thinning (decrease) in the density of bone tissue structures.

Provoking factors:

• infection of bone tissue;
• rheumatoid arthritis;
• diabetes;
• hereditary predisposition;
• multiple sclerosis;
• senile dementia;
• thinness of people with thin bones, low muscle mass, asthenic body type;
• abuse of diuretic diuretics, leading to bone loss;
• sedentary lifestyle;
• poor nutrition;
• bad habits (alcohol, smoking);
• abuse of steroid drugs;
• doing strength sports.

Let's celebrate! In children, the cause of a hip fracture can be a strong blow, a fall from a height, or the development of a pathological process in the femur.

Symptoms and signs

The main symptoms of a hip fracture are sharp burning pain, deformation (shortening) of the affected limb in the case of a displaced fracture. An x-ray will help identify the exact picture of the lesion.

If unpleasant symptoms appear, patients are not recommended to delay contacting doctors. After all, even with a serious injury, the symptoms can be blurred and unclear.

It happens that the pain radiates to the groin area and it is not always possible to immediately understand that it is the femoral neck that is broken, which is fraught with serious complications:

• accumulation of blood in the joint capsule;
• necrosis of the joint head;
• puncture of a large blood artery by a bone fragment.

Symptoms of a hip fracture:

• shortening of the affected limb by 2-3 cm against the background of a sharp muscle contraction;
• the appearance of a tumor, hematoma;
• stiffness of movements;
• inability to stay in an upright position.

Usually, with a broken joint, it is impossible to move the foot or turn it to the side. A reliable sign of a femoral neck fracture is rotation of the foot, everting outward, unnatural presentation of the foot, especially when taking a supine position. The pain is sharp even with slight tapping on the heel.

REFERENCE! In medicine, the term “stuck heel” is known when, with a fracture of the femoral neck, it is impossible to tear the leg off the bed, although the knee is completely bent and unbent. When you turn your neck or body, you can hear a characteristic crunch. Signs of a fracture may be similar to a dislocation, bruise, or sprain. The phenomena should not be ignored. Otherwise, disability and even death may occur.

Fracture classification

The femur bone consists of two joints and many anatomical structures. A fracture can occur at almost any part of the bone. It is the femoral part that is classified according to ICD 10 code.

Taking into account the location and degree of damage by type, a fracture can be:

• closed when there is no communication between the bone and the external environment;
• open in case of damage to the bone together with the skin when an open oozing wound appears.

Taking into account the location of the fracture, the fracture is distinguished: intra-articular, condylar. Along the line: straight, oblique, helical. Depending on the area of ​​displacement, the shape of the fracture is:

• lateral for damage to the lesser and greater trochanter;
• diaphyseal with damage to the lower third of the thigh with the appearance of moderate pain, spreading to the knee;
• medial for damage to the femoral neck and head.

On a note! With an open fracture, diagnosis is not particularly difficult, since bone fragments are visible through the wound. Severe bleeding should not be ignored and you should immediately go to the emergency room. Blood loss leads to loss of consciousness, panic attacks, traumatic shock, and cardiac dysfunction.

Diagnostic methods

In case of damage to the upper part of the femur, diagnostic methods are instrumental:

• radiography to determine the extent and location of the damaged area;
• computed tomography to clarify the complexity of the femur injury;
• MRI for suspected intra-articular fracture.

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Treatment of hip fracture

First of all, the patient should be given first aid:

• applying a tight bandage, Dieterichs splint to fix the affected area, from the armpit to the outside of the ankle;
• fixing the foot at a right angle;
• administration of an anesthetic drug.

The optimal treatment method is selected by a traumatologist based on the diagnostic indications. Treatment is conservative, medications. If there are contraindications or in severe cases, surgical intervention is required.

It is important for patients to maintain bed rest. The immobilized leg should be provided with complete rest.

Conservative treatment

Medication therapy is more often prescribed if there are contraindications to surgery, diseases of the cardiovascular system, or prevent elderly patients.

The main indication for drug treatment is an uncomplicated fracture without displacement of fragments:

• narcotic analgesics;
• painkillers to relieve pain, support blood circulation, respiratory function;
• infusions with intravenous administration of glucose solution, sodium chloride. Reopoliglyukina.

REFERENCE! In contrast to the surgical method, a conservative approach to treatment leads to bedsores, the development of infectious diseases, and congestion in the lungs. When choosing a technique, the doctor takes into account the contraindications that exist in elderly patients who are unable to perform the operation.

In case of a fracture, the optimal treatment option is surgical intervention. In most cases, it is necessary to set the failed joint and restore it in the postoperative period; bone fusion takes place in a shorter time.

If conservative treatment methods become ineffective, then alternative options may be prescribed:

• skeletal traction;
• joint replacement;
• osteosynthesis with the introduction of metal structures to fix bone fragments with subsequent fusion;
• use of plates, structures (pin, sivash corkscrew);
• application of a Beler splint with additional administration of painkillers.

Pain and crunching in the back can lead to dire consequences over time - local or complete limitation of movements, even disability.

People, taught by bitter experience, use natural remedies recommended by orthopedists to cure their backs and joints...

Surgical intervention

When a femoral neck is fractured, many doctors insist on urgent surgery, and in the first 3-5 days to get a better chance of rapid healing of fresh fractures.

Applicable types of intervention:

• application of a plaster cast with a period of immobilization of 1.5 months;
• skeletal traction in case of fracture of the bone body, displacement of fragments with suspension of a weight to the condyles to reduce the displaced fragments to the place;
• osteosynthesis under anesthesia for a fracture of the pelvic bones with stretching of bone fragments with screws, followed by a rehabilitation period for patients who walk on crutches;
• endoprosthetics with replacement of the affected bone with an implant;
• reposition of bone fragments with internal fixation;
• open reduction with treatment of fragments of the epiphysis of the femur, partial (complete) replacement of the hip joint.

Rehabilitation

In case of a hip fracture, rehabilitation measures should begin as quickly as possible. This will avoid the formation of callus, muscle atrophy, and disability.

Physiotherapy

The recovery program is comprehensive:

• massage up to 2 times a day;
• breathing exercises according to Strelnikova’s method;
• a therapeutic diet containing plant fiber to increase the body's resistance and eliminate constipation when patients remain in forced immobility for a long time;
• physiotherapy (electrophoresis, iontophoresis, magnetic therapy) to relieve inflammation, relieve pain and swelling, normalize the trophic metabolism of soft tissues in the operated areas;
• magnetic therapy;
• laser therapy;
• local cryotherapy with 5-10 sessions.

It is important for patients to be active immediately after surgery, turn over in bed, carry out isometric muscle tension of the limbs and lift the torso, leaning on a Balkan frame suspended above the pastel, and carry out breathing exercises until the end of the fracture healing process.

The main thing is to prevent degenerative changes in the joint, which can subsequently lead to limited mobility of the foot.

Important: continue recovery at home every day, carry out massage and physical therapy, include foods containing vitamin D, calcium, phosphorus in your diet, and do not refuse physical therapy sessions.

Hip fractures in children

The phenomenon in children is not as common as in elderly patients. Causes:

• bone fragility;
• lack of vitamin D in the body;
• falling from height;
• a strong kick when playing, in a fight;
• wearing shoes that don't fit;
• frequent stumbling;
• driving in a car without protective seats;
• thinness;
• poor nutrition, lack of bone tissue receiving important minerals.

REFERENCE! Children can break their femoral neck even if they fall from their own height. Until 7 years of age, the periosteum and femoral bones are quite flexible.

Treatment of a hip fracture is carried out by applying an aseptic dressing. For an open fracture - pain relief with analgesics. Next, the doctor will select the optimal method of therapy (surgical, non-surgical) depending on the type of injury.

Forecast

Elderly patients, who often have concomitant chronic diseases, are not immune from complications in the event of a hip fracture. The rehabilitation period is usually long. Additional occurrence of bedsores is inevitable.

Other complications due to long-term immobility of the joint:

• pneumonia;
• venous thromboembolism;
• improper (incomplete) fusion of bones due to impaired blood supply.

If the fracture line is high, it can lead to disability.

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2013

Fracture of unspecified part of femur (S72.9)

Traumatology and orthopedics

general information

Short description

Approved by the minutes of the meeting
Expert Commission on Health Development Issues
No. 18 of the Ministry of Health of the Republic of Kazakhstan dated September 19, 2013

Hip fracture- damage to the femur with disruption of its integrity as a result of injury or pathological process.

Protocol name:"Fractures of the femur"
Protocol code:

ICD-10 codes:
S72 Fracture of the femur

The following subcategories are provided for optional use to further characterize a condition where multiple coding to identify fracture and open wound is not possible or practical; If a fracture is not designated as closed or open, it should be classified as closed:

0 - closed
1 - open
S72.0 Fracture of the femoral neck
S72.1 Pertrochanteric fracture
S72.2 Subtrochanteric fracture
S72.3 Fracture of the body (shaft) of the femur
S72.4 Fracture of the lower end of the femur
S72.7 Multiple fractures of the femur
S72.8 Fractures of other parts of the femur
S72.9 Fracture of unspecified part of the femur

Abbreviations used in the protocol:
HIV - human immunodeficiency virus
Ultrasound - ultrasound examination
ECG - electrocardiogram

Date of development of the protocol: year 2013.
Patient category: patients with femur fractures.
Protocol users: traumatologists, orthopedists, surgeons in hospitals and clinics.

Classification

Clinical classification

According to the nature of soft tissue damage:
- closed;
- open.

According to the location of the fracture site:
- epiphyseal;
- metaphyseal;
- diaphyseal.

By displacement of fragments:
- without displacement;
- with offset.

International classification of JSC (Association of Osteosynthesis)

Based on location, femur fractures are divided into three segments:

1. Proximal segment

2. Middle (diaphyseal) segment

3. Distal segment

1. Injuries to the proximal femur
A1- periarticular fracture of the trochanteric zone, pertrochanteric simple:
1 - along the intertrochanteric line;
2 - through the greater trochanter + detailing;
3- below the lesser trochanter + detailing.
A2- periarticular fracture of the trochanteric zone, pertrochanteric comminuted:
1 - with one intermediate fragment;
2 - with several intermediate fragments;
3 - extending more than 1 cm below the lesser trochanter.
A3- periarticular fracture of the trochanteric zone, intertrochanteric:
1 - simple oblique;
2 - simple transverse;
3 - splintered + detailing.
IN 1- periarticular neck fracture, subcapital, with slight displacement:
1 - impacted with valgus more than 15° + detailing;
2 - impacted with valgus less than 15° + detailing;
3 - not hammered in.
AT 2 - periarticular neck fracture, transcervical:
1 - basiccervical;
2 - through the middle of the neck, adduction;
3 - transcervical from shear.
AT 3- periarticular neck fracture, subcapital, displaced, non-impacted:
1 - moderate displacement with external rotation;
2 - moderate displacement along the length with external rotation;
3 - significant displacement + detail.
C1- intra-articular head fracture, splitting (Pipkina):
1 - separation from the place of attachment of the round ligament;
2 - with a rupture of the round ligament;
3 - large fragment.
C2- intra-articular fracture of the head, with depression:
1 - postero-superior part of the head;
2 - anterosuperior part of the head;
3 - splitting with indentation.
NW- intra-articular fracture of the head with a fracture of the neck:
1 - splitting and transcervical fracture;
2 - splitting and subcapital fracture;
3 - depression and fracture of the neck.

2. Damage to the diaphyseal segment of the femur
A1- simple fracture, spiral:
1 - subtrochanteric region;
2 - middle section;
3 - distal section.
A2- simple fracture, oblique (>30°):
1 - subtrochanteric region;
2 - middle section;
3 - distal section.
A3- simple fracture, transverse (<30°):
1 - subtrochanteric region;
2 - middle section;
3 - distal section.
IN 1 - wedge fracture, spiral wedge:
1 - subtrochanteric region;
2 - middle section;
3 - distal section.
AT 2- wedge-shaped fracture, wedge from flexion:
1 - subtrochanteric region;
2 - middle section;
3 - distal section.
AT 3- wedge-shaped fracture, fragmented wedge + detailing for all subgroups:
- subtrochanteric region;
- middle section;
- distal section.
C1- complex fracture, spiral + detailing for all subgroups:
- with two intermediate fragments;
- with three intermediate fragments;
- more than three intermediate fragments.
C2- complex fracture, segmental:
- with one intermediate segmental fragment + detailing;
- with one intermediate segmental and additional wedge-shaped
fragments + detailing;
- with two intermediate segmental fragments + detailing.
NW- complex fracture, irregular:
1 - with two or three intermediate fragments + detailing;
2 - with fragmentation in a limited area (<5 см) + детализация;
3 - with widespread fragmentation (>5 cm) + detailing.

3. Damage to the distal femur
A1- periarticular fracture, simple:
1 - apophysis detachment + detailing;
2 - metaphyseal oblique or spiral;
3 - metaphyseal transverse.
A2- periarticular fracture, metaphyseal wedge:
1 - intact + detailing;
2 - fragmented, lateral;
3 - fragmented, medial.
A3- periarticular fracture, complex metaphyseal:
1 - with a split intermediate fragment;
2 - irregular shape, limited to the metaphysis zone;
3 - irregularly shaped, extending to the diaphysis.
IN 1- incomplete intra-articular fracture of the lateral condyle, sagittal:
1 - simple, through the tenderloin;

3 - splintered.
AT 2- incomplete intra-articular fracture of the medial condyle, sagittal:
1 - simple, through the tenderloin;
2 - simple, through the loaded surface;
3 - splintered.
AT 3- incomplete intra-articular fracture, frontal:
1 - fracture of the anterior and outer and lateral parts of the condyle;
2 - fracture of the posterior part of one condyle + detailing;
3 - fracture of the posterior part of both condyles.
C1- complete intra-articular fracture, articular simple, metaphyseal simple:
1 - T- or Y-shaped with slight offset;
2 - T- or Y-shaped with pronounced displacement;
3 - T-shaped epiphyseal.
C2- complete intra-articular fracture, articular simple, metaphyseal
splintered:
1 - intact wedge + detailing;
2 - fragmented wedge + detailing;
3 - difficult.
NW- complete intra-articular fracture, articular comminuted:
1 - metaphyseal simple;
2 - metaphyseal comminuted;
3 - metaphyseal-diaphyseal splintered.

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of basic and additional diagnostic measures

Basic diagnostic measures before/after surgical interventions:
1. General blood test
2. General urine test
3. X-ray of the hip
4. Examination of stool for helminth eggs
5. Microreaction
6. Determination of glucose
7. Determination of clotting time, duration of bleeding
8. ECG
9. Biochemical blood test
10. Determination of blood group and Rh factor

Additional diagnostic measures before/after surgical interventions:
1. Troponins, BNP, D-dimer, homocysteine ​​(according to indications)
2. HIV testing
3. X-ray of the chest, spine, skull and limbs
4. Computed tomography
5. Ultrasound of the abdominal and pelvic organs, kidneys,
6. Immunogram (according to indications)
7. Cytokine profile (interleukin-6.8, TNF-α) (according to indications)
8. Markers of bone metabolism (osteocalcin, deoxypyridinoline) (according to indications)

Diagnostic criteria.

Complaints: for pain, impaired ability to support the limb, the presence of wounds due to open fractures.

Anamnesis: presence of injury. Trauma genesis is taken into account. Direct impacts during car and motorcycle injuries, “bumper” fractures in pedestrians, falls from heights, landslides and various accidents. The magnitude of the acting force (mass), the direction of influence, and the area of ​​application of the force are assessed.
The mechanism of injury can be either direct (a strong blow, heavy objects falling on the leg) or indirect (sharp rotation of the lower leg with a fixed foot). In the first case, transverse fractures occur, in the second - oblique and helical ones. Comminuted fractures are common.

Physical examination

Absolute (direct) signs of fractures:
- hip deformation;
- bone crepitation;
- pathological mobility;
- protrusion of bone fragments from the wound;
- shortening of the limb.

Relative (indirect) signs of fractures:
- pain (coincidence of localized pain and localized tenderness on palpation);
- symptom of axial load - increased localized pain when the limb is loaded along the axis;
- presence of swelling (hematoma);
- impairment (absence) of limb function.
The presence of even one absolute sign gives grounds to diagnose a fracture.

Symptoms of bone crepitus and pathological mobility should be checked carefully; if there are obvious signs of a fracture, do not check!

Laboratory research: not informative.

Instrumental studies: To establish a diagnosis, radiography must be performed in two projections. Sometimes with fractures of the proximal segment, computed tomography is required for clarification.

Indications for specialist consultation is a combination of hip fractures with other organs and systems, as well as concomitant diseases. In this connection, if necessary, consultations with a neurosurgeon, surgeon, vascular surgeon, urologist, therapist, and other specialists according to indications can be scheduled.

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Treatment

Goal of treatment: elimination of displacement and fixation of bone fragments, restoration of limb function.

Treatment tactics

At the prehospital stage:
- for open fractures - stop bleeding (pressure bandage, pressing the vessel, applying a tourniquet), applying a sterile bandage. Do not reduce bone fragments protruding from the wound!
- transport immobilization: use pneumatic, vacuum tires, Dieterichs, Kramer tires. The hip, knee and ankle joints should be fixed. You can also bandage the injured limb to the healthy leg (so-called autoimmobilization); a board with soft material should be laid between the limbs at the level of the knee joints and ankles;
- cold on the damaged area.

Mode depending on the severity of the condition - 1, 2, 3. Diet - 15; other types of diets are prescribed depending on the concomitant pathology.

Drug treatment

Basic medications:
- pain relief non-narcotic analgesics - (for example: ketorolac 1 ml/30 mg IM);
- for severe pain, narcotic analgesics - (for example: tramadol 50 - 100 mg IV, or morphine 1% - 1.0 ml IV, or trimeperidine 2% - 1.0 ml IV, you can add diazepam 5- 10 mg IV).

Additional medications:
- for symptoms of traumatic shock: infusion therapy - crystalloid (for example: sodium chloride solution 0.9% - 500.0-1000.0, dextrose 5% - 500.0) and colloid solutions (for example: dextran - 200 -400 ml., prednisolone 30-90 mg);
- immunocorrectors.

Conservative treatment: application of a plaster splint or coxite plaster cast or circular bandage, application of skeletal traction.

Surgical intervention:
78.15 - Application of an external fixation device on the femur;
78.45 - Other restorative and plastic manipulations on the femur;
78.55 - Internal fixation of the femur without reduction of the fracture;
79.15 - Closed reduction of bone fragments of the femur with internal fixation;
79.151 - Closed reduction of bone fragments of the femur with internal fixation by intramedullary osteosynthesis;
79.152 - Closed reduction of bone fragments of the femur with internal fixation with a locking extramedullary implant;
79.25 - Open reduction of bone fragments of the femur without internal fixation;
79.35 - Open reduction of bone fragments of the femur with internal fixation;
79.351 - Open reduction of bone fragments of the femur with internal fixation by intramedullary osteosynthesis;
79.45 - Closed reduction of fragments of the epiphyses of the femur;
79.45 - Open reduction of fragments of the epiphyses of the femur;
79.65 - Surgical treatment of an open fracture of the femur.
81.51 - Total hip replacement;
81.52 - Partial hip replacement.

Depending on the level of fracture, the following is used in clinical practice:
- For fractures of the proximal femur (femoral neck, trochanteric region), depending on the age and duration of the injury, osteosynthesis or unipolar or total hip arthroplasty is used.
- For fractures of the diaphyseal region and distal metaepiphysis of the femur, osteosynthesis is used with various fixators (extrafocal, extramedullary, intramedullary, combined).

Preventive measures (prevention of concomitant diseases) :

Drugs for the prevention and treatment of fat embolism and thromboembolic complications (nadroparin calcium 0.3 ml * 1-2 times a day s.c., enoxaparin 0.4 ml * 1-2 times a day s.c., fondaparinux sodium 2.5 mg * 1 once a day, rivaroxaban 1 tablet * 1 time a day);
- vasocompression of the lower extremities using elastic bandages or stockings.
To prevent pneumonia, early activation of the patient, exercise therapy, breathing exercises and massage are necessary.

Further management: in the postoperative period, to prevent suppuration of the postoperative wound, the following is prescribed:
- antibiotic therapy (ciprofloxacin 500 mg IV 2 times a day, cefuroxime 750 mg * 2 times a day IM, cefazolin 1.0 mg * 4 times a day IM, ceftriaxone - 1.0 mg * 2 times a day IM, lincomycin 2.0 2 times a day IM);
- metronidazole 100*2 times a day;
- infusion therapy according to indications.

The patient is activated early, learns to move on crutches without weight-bearing or with weight-bearing (depending on the type of fracture and operation) on the operated limb, and is discharged for outpatient treatment after mastering the technique of walking on crutches.
Control radiographs are taken at 6, 12 and 36 weeks after surgery.
After surgical treatment of fractures, external immobilization is used as indicated.

Rehabilitation: the time of onset of movements in the operated joint is determined by the location of the fracture, its nature, the position of the fragments, the severity of reactive phenomena and the characteristics of the course of reparative processes. It is necessary to strive for the earliest possible start of physical exercise, since with prolonged immobilization of the joint, changes develop that limit its mobility.

Exercise therapy. From the first days after surgery, active management of patients is indicated:
- turning in bed;
- breathing exercises (static and dynamic nature);
- active movements in large and small joints of the shoulder girdle and upper limbs;
- isometric muscle tension of the limbs;
- lifting the body with support from a Balkan frame or trapeze suspended above the bed.

Specialexercisesfor the operated limb is prescribed for to prevent muscle atrophy and improve regional hemodynamics of the injured limb, use:

Isometric tension muscles of the thigh, lower leg and gluteal muscles, the intensity of the tension is increased gradually, duration 5-7 seconds, number of repetitions 8-10 per session;

Active repeated flexion and extension of the toes, flexion and extension in the ankle joints, performed until slight fatigue appears in the calf muscles, which activate the so-called muscle pump and help prevent thrombophlebitis, as well asexercises that train peripheral blood circulation (lowering and then giving an elevated position to the injured limb);

Ideomotor special attention is paid to exercises as a method of maintaining a dynamic motor stereotype, which serves to prevent stiffness in the joints. Imaginary movements are especially effective when a specific motor act with a long-developed dynamic stereotype is mentally reproduced. The effect turns out to be much greater if, in parallel with the imaginary ones, this movement is actually reproduced by a symmetrical healthy limb. During one lesson, 12-14 ideomotor movements are performed;

U exercises aimed at restoring the supporting function of the uninjured limb (dorsal and plantar flexion of the foot, grasping various small objects with the toes, axial pressure with the foot on the headboard or footrest);

Postural exercises or positional treatment - placing the limb in a corrective position. It is carried out using splints, fixing bandages, splints, etc. Treatment by position is aimed at preventing pathological positions of the limb.To reduce pain in the fracture zone and relax the muscles of the pelvic girdle, thigh and lower leg muscles, you should place alive cotton-gauze roller, the size of which must be changed during the day. The procedure time is gradually increased from 2-3 to 7-10 minutes. Alternation passive flexion followed by extensionremoval (by removing the cushion) in the knee joint improves movements in it;

Relaxation exercises involve consciously reducing the tone of various muscle groups. To better relax the muscles of the limb, the patient is given a position in which the attachment points of tense muscles are brought closer together. To teach the patient active relaxation, swing movements, shaking techniques, and a combination of exercises with prolonged exhalation are used;

Exercises for joints of the operated limb that are free from immobilization, which help improve blood circulation and activate reparative processes in the damaged area;

Exercises for a healthy symmetrical limb, to improve the trophism of the operated limb;

Lighter movements in the joints of the operated limb are performed with self-help, with the help of a physical therapy instructor.

Mechanotherapy
Prescribed for limited range of motion in the knee and hip joints. Its goal is to increase mobility in an isolated joint, which is achieved by dosed stretching of the periarticular tissues under the condition of muscle relaxation. The effectiveness of the effect is due to the fact that passive movement in the joint is carried out according to an individually selected program (amplitude, speed), for example, on the “Artromot” devices. The number of classes is gradually increased from 3-5 to 7-10 per day.

The question of the duration of bed rest after surgical treatment of fractures is decided in each case individually. With the early onset of dosed functional load under conditions of stable osteosynthesis, there is an increase in blood supply to the damaged area of ​​the injured limb. First, the patient sits independently on the bed, then he is transferred to a vertical position. First, you should stand by the bed, holding onto its back.

Patients learn to move with the help of crutches - first within the ward, then in the department (without putting any weight on the operated leg!). When learning to move with the help of crutches, you should remember that both crutches must be carried forward at the same time, standing on your healthy leg. Then they put the operated leg forward and, leaning on crutches and partly on the operated leg, take a step forward with the non-operated leg; standing on the healthy leg, the crutches are brought forward again. It must be remembered that the weight of the body when leaning on crutches should be on the hands, and not on the armpit. Otherwise, compression of the neurovascular formations may occur, which leads to the development of so-called crutch paresis.

To restore correct posture and walking skills, classes include general strengthening exercises covering all muscle groups, performed in the initial position lying, sitting and standing (with support on the headboard).

Physical treatments are aimed at reducing pain and swelling, relieving inflammation, improving trophism and metabolism of soft tissues in the surgical area. Apply:
- local cryotherapy;
- ultraviolet irradiation;
- magnetic therapy;
- laser therapy.
The course of treatment is 5-10 procedures.

Indicators of treatment effectiveness and safety of diagnostic and treatment methods described in the protocol:
- satisfactory position of bone fragments on control radiographs;
- restoration of function of the damaged limb.

Drugs (active ingredients) used in treatment

Hospitalization

Indications for hospitalization : indications for emergency hospitalization are patients with femoral fractures of all types.

Information

Sources and literature

1. Minutes of meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013
   1. 1. Müller M.E., Allgover M., Schneider R. et al. Guide to internal osteosynthesis. Methodology recommended by the AO group (Switzerland). - trans. from English Ad Marginem. - M. - 2012. 2. Michael Wagner, Robert Frigg AO Manual of Fracture Management: . Thieme, 2006. 3. Neubauer Th., WagnerM., Hammerbauer Ch. System of plates with angular stability (LCP) - a new AO standard for external osteosynthesis // Vestn. traumatol. orthopedist. - 2003. - No. 3. - P. 27-35. 4. Advanced trauma life support, eighth edition, 2008 5. N.V. Lebedev. Assessment of the severity of the condition of patients in emergency surgery and traumatology. M. Medicine, 2008.-144 p.

Information

III. ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION

List of protocol developers with qualification information:
Dosmailov B.S. - Head of the Department of Traumatology No. 2, Scientific Research Institute of Traumatology and Orthopedics, Ph.D.
Dyriv O.V. - manager Department of Rehabilitation of Scientific Research Institute of Traumatology and Orthopedics
Baimagambetov Sh.A. - deputy Director of Scientific Research Institute for Clinical Work, Doctor of Medical Sciences The most complete database of clinics, specialists and pharmacies in all cities of Kazakhstan.