RU2152184C1 - Method for rebuilding hand on all fingers amputation stumps - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves forming back and palmar feeding pedicles in the third metacarpal bone projection in retaining connecting skin strips in the stump end zone. Distraction being over, the feeding pedicles are mobilized at the second stage with connecting skin strips being transected. Transverse osteotomy of the fragment to be moved is carried out forming parts which sizes enable the fourth and the first equal-sized radii to be formed. The posterior feeding pedicle is transected at the osteotomy level. The distal part of the fragment is transferred to the first radius stump on the palmar feeding pedicle. The proximal part of the fragment is transferred to the fourth radius stump on the posterior feeding pedicle. Skin defects are substituted on the rebuilt radii with tubular skin-and-fat flap. EFFECT: improved grasping hand function. 8 dwg

Description

 The present invention relates to medicine, in particular to surgery, and can be used in the reconstruction of a fingertip brush.

 There are various methods for reconstructing a fingered brush, for example, by distraction lengthening of the stump of the first ray and stump of the fourth ray (see M. I. Dadalov "Reconstructive surgery for the loss of the thumb". Abstract of diss. Candidate of Medical Sciences in the form of a scientific report, Leningrad, 1990, p. 42).

 However, this method does not allow to reach the dilution of the formed "fingers" more than 50 mm, which limits the functionality of the brush. In addition, it cannot be realized with short stumps of the fingers and metacarpal bones, requires long periods of treatment and is accompanied by partial resorption of the bone skeleton of the recovery rays.

 There is also a method of reconstructing the stump of the hand, which consists in a one-stage movement of the longitudinal segment of the second metacarpal bone on the feeding legs on the stump of the first finger (see A. St. N 1118354, A 61 B 17/00, 1984).

 However, according to this method, only the first beam can be reconstructed and for limited indications, namely: with a longer length of the segment being moved than the being restored. The method does not provide adequate prevention of ischemic complications when moving a bone fragment of a pathologically altered stump of a finger or metacarpal bone. In addition, with this method, the integrity of the skin of the first interdigital gap is violated, which may be accompanied by the formation of adducing contracture in the wrist-metacarpal joint of the formed first ray.

 As a prototype, we have chosen the method of phalangization of a fingerless hand, which consists in applying an external fixation apparatus to the hand and forearm and two-stage distraction movement of fragments of the second metacarpal bone to the distal end of the first and third metacarpal bones (see application N 92009749/14 of 07.12.92 g. , A 61 B 17/56, BI N 32, p. 13).

 However, the known method allows you to move fragments of the metacarpal bone only on the stump of adjacent rays, while the distance between the restored rays is insufficient to grasp and hold medium and large objects. The method does not make it possible to use pathologically altered stumps of fingers and metacarpal bones for ray reconstruction, since it does not prevent the ischemic complications that inevitably develop when moving such segments. When implementing the method, the integrity of the skin of the first interdigital gap is violated, which can lead to the formation of leading contracture of the first ray and a sharp violation of the function of the crippled brush.

 The problem to which the proposed technical solution is directed is to improve the grasping function of the hand in the stumps of all of her fingers by increasing the distance between the restored simultaneously anti-resistant branches.

 This problem is solved due to the fact that in a method that includes an osteotomy of a movable ray stump, dilution of its fragments by an external fixation apparatus, separation of the distal fragment into two parts and their subsequent movement, the back and palmar feeding legs are formed in the projection of the stump of the third metacarpal at the first stage leaving skin lintels in the region of the butt end of the stump, after completion of distraction, at the second stage, feeding legs are mobilized with the intersection of skin lintels, transverse osteotomy of the transferred fragment with by developing parts, the dimensions of which allow the formation of equal fourth and first rays, cross the back feeding leg at the level of the osteotomy and move the distal part of the fragment to the stump of the first beam on the palmar feeding leg, and the proximal to the cult of the fourth ray on the back feeding leg, replacing skin defects with reconstructed rays with a tubular skin-fat flap.

 The method of reconstructing the brush with amputation stumps of all fingers is illustrated by drawings, where in FIG. 1 shows the stage I of the operation, the palmar feeding leg is formed with the preservation of the skin bridge in the region of the end face of the moved stump; in FIG. 2 - stage I of the operation, the back feeding leg is formed with preservation of the skin bridge in the region of the end face of the moved stump; in FIG. 3 - stage I of the operation, the distracted palmar feeding leg and the distal fragment of the third ray; in FIG. 4 - stage II of the operation, the distracted back feeding leg and the distal fragment of the third ray; in FIG. 5 - stage II of the operation, the distal part of the stump of the third ray is moved on the palmar feeding leg to the stump of the first ray; in FIG. 6-stage II of the operation, the proximal part of the stump of the third ray is moved on the back feeding leg to the stump of the fourth ray.

 The method is as follows.

 The method is implemented in two stages. At the first stage, feeding legs (palmar 1 and back 2) are formed (see Figs. 1, 2). To do this, parallel skin incisions are made in the projection of the intercarpal spaces of the moved stump of the beam on the rear and on the palm of the hand: when moving the third beam, in the second and third intercarpal spaces, the fourth in the third and fourth intercarpal spaces. Then, in the same projection, the palmar aponeurosis and the dorsal fascia of the hand are dissected in layers, the metacarpal ligaments and the inter-tendon lintels on the rear of the hand cross. The dimensions on the rear and on the palm end at a distance of 1 cm from each other in the region of the butt end of the stump, without crossing the skin bridge 3 (see Fig. 1, 2). The metacarpal bone is completely mobilized in the metacarpal spaces by cutting off the back and palmar interosseous muscles from it. Finger nerves are split longitudinally to the proximal metaepiphysis of the transported beam. Perform transverse osteotomy of the metacarpal bone in the proximal metaepiphysis (see Fig. 1). Through the distal fragment of the metacarpal bone and the stump of the main phalanx of the finger, the Kirschner needle is passed itramedullary. Its distal end is brought out through the end, and the proximal end is fixed to the movable fragment of the metacarpal bone. Wounds are sutured in layers. An external fixation device is applied to the forearm and hand, and after reducing postoperative edema and subsiding pain in the wound, axial distraction of the stump of the beam begins with the surrounding tissues 1-2 mm per day, monitoring the state of blood circulation in the stump. The distraction is carried out to such an extent that the proximal end of the distracted segment is at least at the same level with the distal end of the stump of the restored elbow ray. After distraction is completed, after 1.5 - 2 months, the second stage of the operation is performed - restoration of the first and fourth rays. For this, cuts of the skin and underlying tissues are performed along the scars after the first stage of the operation with the intersection of skin lintels 3 (see Fig. 3, 4). The distracted segment is mobilized on the palmar and back feeding legs and an osteotomy of the distracted fragment is performed, departing from the end of the bone by a distance equal to half the total length of the third and fourth rays, minus the length of the first ray. As a result of osteotomy, the distracted fragment is divided into two parts (see Figs. 3, 4): distal 4 and proximal 5. Then the back feeding leg 2 is crossed at the level of the osteotomy performed (see Fig. 4) and the distal part of the distracted segment is mobilized on the palmar feeding leg, and proximal on the back feeding leg. The ends of the restored stumps are refreshed and the receptive bed for the moving knives of the moved parts of the distracted stump is formed: for this, a skin incision is made on the palm connecting the base of the palmar feeding leg to the end of the stump of the first ray, and on the back - the base of the feeding leg with the end of the stump of the restored elbow ray and mobilize the edges of the wounds to the width of the feeding legs. Then the distal part 4 of the distracted stump is moved on the palmar feeding leg 1 to the stump of the first beam (see Fig. 5), and the proximal part 5 on the back feeding leg 2 - to the stump of the restored ulnar beam (see Fig. 6), laying the feeding legs into the formed box. Osteosynthesis of displaced bone fragments with stumps of rays is performed, the wounds are sutured and skin defects on the lateral and end surfaces of the ulnar beam are replaced by a tubular skin-fat flap from a distant part of the body. The brush is fixed with a plaster cast for the period of consolidation of bone fragments.

 Clinical example.

 Gnoy S.V., 20 years old, source. bol. N 160708, was in the Department of Hand Surgery NNIITO with the diagnosis: Cult 1 - 5 fingers of the right hand at the level of the proximal third of the main phalanges.

 From the anamnesis it is known that the patient suffered as a result of frostbite of the hands. On admission, stumps of 1 to 5 fingers are determined at the level of the proximal thirds of the main phalanges (see x-ray of the hand before surgery). The length of the stump of the fingers varies from 2 to 4 cm. Their ends are pathologically altered - there are dense scars welded to the underlying tissues. The movements of the stumps in the metacarpophalangeal joints are preserved. A sharp restriction of the function of the hand is noted: it is possible to contrast the stump of the first finger only to the stump of the second finger, the patient cannot hold both small and large objects with the brush.

 In order to improve the function of the hand, the patient underwent rehabilitation treatment. Previously, the patient was formed stalk Filatov. Next, the first stage of the operation was performed according to the developed technique, and after the completion of distraction, the second stage of the operation. In this case, the first and fourth rays were restored simultaneously. Defects of soft tissues formed on the lateral and end surfaces of the restored fourth ray are covered by a preformed Filatov stalk. Upon repeated admission, the stump of the first finger was corrected with the elimination of its flexion contracture.

 As a result of the treatment, 1 and 4 rays 13 cm long were restored to the patient, which made it possible to contrast the first “finger” with all other finger stumps. The breeding of the anti-resistant branches was 8 cm. The discriminatory sensitivity on the working surface of the restored finger was 5 cm. The patient grips and holds with a brush both small and large objects up to 8 cm in diameter. When radiography of the restored "fingers" is noted, the stability of their bone skeleton to resorption processes (see x-ray of the hand after surgery). For example, after surgery, the length of the first "finger" was 70 mm, 4 fingers - 38 mm, and 2 years after reconstructive treatment - 70 mm and 37 mm.

 Thus, the method makes it possible to form “fingers” with a bone skeleton resistant to resorption processes, which indicates the adequacy of its blood supply.

 The developed method allows you to simultaneously restore two beams at once and significantly improve the function of the hand by moving segments of the least functional stump of the finger or metacarpal bone during stumps of the hand at different levels. Moreover, depending on the specific anatomical situation, the method allows you to move the stump of not only the second and third, but also the fourth and fifth rays. In this case, the patient has the opportunity to hold both small and large objects with a brush.

 Surgical training, which consists in the formation of the feeding legs of the segment with its subsequent distraction, provides adequate prevention of ischemic complications in both movable segments, which allows the stumps of the fingers and metacarpal bones to be moved even with severe degrees of pathological changes in their soft tissues.

 The developed formula makes it possible to choose the necessary level of osteotomy and form two equal-sized rays.

 When implementing the method, the skin of the first interdigital gap is intact, which eliminates the possibility of developing cicatricial contracting of the first ray and limiting the function of the brush. Moreover, a result adequate to the results of a finger transplant from the foot is achieved exclusively at the expense of local tissue resources, without causing damage to donor sites from remote areas of the body.

 The method is effective, does not require the use of expensive tools and can be implemented by specialists involved in brush surgery.

Claims (1)

 A method for reconstructing the hand in amputation stumps of all fingers by osteotomy of a movable ray stump, diluting its fragments with an external fixation apparatus, dividing the distal fragment into two parts and their subsequent movement, characterized in that at the first stage in the projection of the stump of the third metacarpal bone, the back and palmar feeding legs, leaving skin lintels in the area of the butt end of the stump, after the end of distraction in the second stage, the feeding legs are mobilized with the intersection of the skin lintels, perform transverse os theotomy of the moved fragment with the formation of parts whose dimensions allow the formation of equal fourth and first rays, intersect the back feeding leg at the osteotomy level and move the distal part of the fragment to the stump of the first beam on the palmar feeding leg, and the proximal to the stump of the fourth ray on the back feeding leg with replacement of skin defects on the restored rays with a tubular skin-fat flap.

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