RU2210334C1 - Method for combined plasty of thumb's stump - Google Patents

Abstract

FIELD: medicine, surgery. SUBSTANCE: the suggested method deals with developing cutaneous radial fragment, mobilizing radial artery, taking up osseous fragment with periosteum, carrying out osteosynthesis of osseous fragment together with the 1st radius' stump and covering the finger with radial fragment with subsequent suturing the wound on wrist and antebrachium. The novelty deals with development of sharp stalk, after resection from donor's site and turning Filatov's stalk sutured to finger's stump at the border of inferior and middle third of antebrachium one should develop cutaneous fragment by including lateral cutaneous nerve of antebrachium with muscular coupling, carry out osteosynthesis of distal fragment of radius with finger's stump, suture fragment's nerve with stump of finger's nerve and cover proximal end of fragment with muscular coupling and arterial stump, working surface of developed finger - with cutaneous fragment, and its rear-radial surface - with stalk followed by substitution of radius defect for cortical allotransplant as a dowel the end of which are introduced into bone marrow canal and suturing the wound at the level of middle and inferior third of antebrachium that increases finger's function, decreases cosmetic defect and prevents fracture of donor's bone. EFFECT: higher efficiency of combined plasty. 10 dwg, 1 ex

Description

 The invention relates to medicine, and specifically to surgery of the hand, and for plastics of the stump of the finger.

 There are various methods of plastic surgery of the stump of a finger of the hand, for example, the method of plastic surgery with a radiation graft (see Yu. Yu. Kolontay et al. Surgery for damage to the hand, Dnepropetrovsk, 1997, pp. 319-321). However, when using this method, a soft tissue defect in the donor region is closed with a free skin graft, which leads to the formation of a pronounced cosmetic defect on the forearm.

 Closest to the proposed technical solution is the method of plastics of the first finger of the brush, described in the article by A.F. Krasnova, V.M. Evdokimova "Reconstruction of the first finger using a" Chinese flap ", g." Orthopedics, traumatology and prosthetics ", 1990, 7, S. 38 and 39. The method consists in the formation of a skin-fat flap in the middle and upper third of the forearm 6-12 cm in size of a rectangular shape, the radial artery is mobilized to the upper third of the forearm.To facilitate closure of the wound on the forearm, multiple incisions are made on the skin.The bone fragment is taken along with the periosteum, the skin flap is folded in half and the entire finger is closed. zhenii lower, middle and upper third of the forearm.

 However, the large flap formed makes it difficult to suture the donor wound, multiple cuts applied to the skin subsequently cause the formation of multiple scars, and suturing the wound with tensioning the edges subsequently leads to stretching of the scar, which will practically occupy the entire palmar surface of the forearm. Mobilization of the radial artery to the upper third of the forearm reduces blood circulation of the surrounding muscles and nerves. The consequence of the fact that the bone fragment is taken without muscle clutch may be a violation of its nutrition, followed by resorption. The resulting regional defect of the radius in some cases may be the cause of its fractures.

 The objective of the invention is the reduction of cosmetic flaws and bone defects of the donor region.

 This problem is solved due to the fact that they form an acute stem, after cutting off from the donor site and expanding the Filatov stem stitched to the finger stump at the border of the lower and middle third of the forearm, a skin flap is formed with the lateral cutaneous nerve of the forearm included, bone is cut out from the radius bone at the level of the flap fragment with a muscular sleeve, osteosynthesis of the distal end of the radius fragment with the stump of the finger is performed, the flap nerve is stitched with the stump of the digital nerve and the proximal end of the muscle fragment is closed with a clutch and stump of an artery, the working surface of the formed finger with a skin flap, and its dorsum-radial surface with a stalk, followed by replacement of the radial bone defect with a cortical allograft in the form of a pin, the ends of which are inserted into the medullary canal, and suturing the wound at the level of the middle and lower third forearms.

 The essence of the proposed technical solution is illustrated by the drawings, in which Fig. 1 shows a sharp Filatov stem stitched to a finger stump, in Fig. 2 - a sharp stalk is cut off from the mother site, a skin-bone flap is formed on the forearm, in Fig. 3 - a skin-bone flap mobilized on the distal part of the radial vascular bundle, Fig. 4 - a skin flap laid on the palmar-ulnar surface of the finger and stitched with the edges of the expanded stem, osteosynthesis of a fragment of the radius with metacarpal bone stump, marginal radius defect is replaced cortical allograft, a donor wound on the forearm is sutured.

 The proposed method is as follows.

 A squamous skin-fat flap is formed on the abdomen with the dimensions of the sides equal to the circumference and length of the restored finger with the addition of 1.5 cm per skin contractility. The flap is folded into a tube, the scars on the finger stump are excised, and the stalk 1 is sutured to the finger stump so that the stitched edges of the flap are on the palm-elbow side of the formed finger (Fig. 1). After 4 weeks, stem 1 is cut off from the abdomen. Departing by the length of the stump of the beam from the level of the wrist joint, an oval-shaped skin-fat radial flap 2 is formed, measuring 6 • 3 cm, retaining vascular connections with the radial artery, which includes the lateral cutaneous nerve of the forearm (Fig. 2). Without breaking ties with the radial artery and the flap, a bone fragment 3 is cut out from the radius at the level of the flap. The length of the bone fragment is equal to the length of the restored finger, and the thickness is 1/3 of the radius of the radius (Fig.2). On the bone fragment 3, the periosteum is preserved and a muscle sleeve 0.5 cm thick is formed that extends beyond the proximal end of the bone fragment by 1.0 cm. The radial vascular bundle is ligated and intersected at the proximal edge of the flap. The flap 2 with a fragment 3 of the radius is mobilized on the distal part of the radial artery 4 to the wrist joint (figure 3). The incision on the forearm is connected to the finger stump, the edges of the wound are mobilized, forming a bed for the feeding leg. Stem 1 is cut along the longitudinal scar and unfold. A complex of tissues is transferred to a finger stump. The distal part of the radial artery 4 is laid in the formed bed. Perform osteosynthesis of the distal fragment of the radial bone 3 with the stump of the finger 5 (figure 4). The proximal end of the fragment is closed with a muscular sleeve and an artery stump. A skin flap 2 is placed on the palm-elbow surface of the finger. An anastomosis of the nerve flap with a stump of the digital nerve is performed. Sew the edges of the flap 2 with the edges of the skin of the stem 1 (figure 4). A cortical allograft 6 is cut out in the form of a pin 0.5 cm thick with an excess of the radius of the radial bone defect of 1.0 cm. The allograft 6 is inserted into the bone marrow canal of the radius, overlapping its defect (Fig. 4). Muscles are sutured above the allograft 6. The wound on the hand is sutured at the level of the lower and middle third of the forearm. The hand and forearm are fixed with a plaster cast for 4 weeks.

 When implementing the method, a skin-fatty radial flap of small sizes is formed, located not higher than the middle third of the forearm. This allows you to close the donor wound without tensioning its edges, which creates the conditions for the formation of a single linear postoperative scar. It is located throughout only the lower and middle third of the forearm.

 Cutting out a small radius flap can also be limited to mobilization of the radial artery to a small extent and maintain blood supply to the muscles of the forearm.

 The formation of a muscular coupling on a fragment of the radial bone allows you to save the blood vessels supplying it. Adequate blood supply to the bone fragment ensures the stability of the skeleton of the restored finger to resorption processes.

 Plastic surgery of the marginal defect of the radial bone reduces a donor defect and provides prophylaxis for its fractures. The proposed method of bone grafting is simple, less traumatic, does not require the use of metal structures for fixation of the graft. The introduction of the allograft ends into the bone marrow canal of the radial bone improves the conditions of its consolidation and subsequent restructuring. The use of an allograft eliminates the need for trauma to another donor area of the patient.

 Clinical example.

 B. N., 57 years old, East. bol. 197292, was treated in Nizhny Novgorod NIIIT with a diagnosis of a stump of the first finger at the level of the head of the metacarpal bone, leading to contracture of the first metacarpal bone, a break in the tendons of the flexors of the second finger, tenogenic contracture of the third finger of the right hand (Fig. 1, 2, 5, 6). From the anamnesis it is known that on January 22, 01, the patient’s hand fell into a circular saw. Upon receipt, there is a lack of bilateral grip of the hand and a sharp restriction of the flexion function of 2, 3 fingers. In order to restore the bilateral grip of the brush, the first finger was reconstructed using the developed method. 06.06.01 plastic surgery of the stump of the first finger was performed with a sharp Filatov stalk formed in the left half of the abdomen (Fig. 3, 7). During the operation, scars were excised in the first interdigital space, which eliminated the leading contracture of the first metacarpal bone, as well as a suture of the tendon of the deep flexor of the second finger, tenolysis of the flexor of the third finger. The postoperative course is smooth, the stem has completely taken root. 07/17/01 skin-bone reconstruction of the first finger was carried out (Fig. 4, 8). At the same time, a complex of tissues was mobilized on the distal part of the radial artery, including a 6–3 cm skin flap, a fragment of the radius with a periosteum and a muscular sleeve. With the help of a skin flap, the working surface of the formed finger is closed, and the stalk - rear-beam. The radius defect is replaced with an allograft. The wound on the forearm is sutured without tension in layers tightly. The postoperative course is smooth. The wounds healed by first intention, the flaps completely healed. The patient was examined after 0.5 years (Fig. 5, 6, 9, 10). Brush grip restored. Perhaps the opposition of the first finger to the second, third fingers. The postoperative scar occupies the lower and middle third of the forearm, has a linear shape, a width of 1-2 mm. The allograft has grown together with the radius. The transplanted fragment of the radial bone retains its original length. The patient is completely satisfied with the functional and cosmetic result of the treatment.

 Thus, the combined use of a skin-bone radial flap with axial blood supply and a skin-fat flap on a temporary feeding leg allows to minimize cosmetic flaws on the forearm. The ability to close a donor wound without using free skin grafts or making additional incisions minimizes cosmetic flaws and successfully performs bone alloplasty of a radius defect.

Claims (1)

 A method of plasticizing a stump of a finger of a hand, including the formation of a skin radial flap, mobilizing it with a fragment of the radial bone on the distal part of the radial artery, osteosynthesis of a bone fragment with a stump of the beam and closing the finger with a radial flap, followed by suturing the wound on the bones and forearm, characterized in that they form an acute the stalk, after cutting off from the donor site and expanding the stitched finger of the stalk of the finger of the Filatov stalk at the border of the lower and middle third of the forearm, a skin flap is formed with the inclusion of the lateral cutaneous nerve of the forearm, a bone fragment with a muscular sleeve is cut out from the radial bone at the level of the flap, osteosynthesis of the distal end of the radius bone fragment with the stump of the finger is performed, the flap nerve is stitched with the stump of the digital nerve and the proximal end of the fragment is closed with the muscular sleeve and artery stump, the working surface of the formed finger - a skin flap, and its dorsum-radial surface with a stalk, followed by the replacement of the radius defect with a cortical allograft in the form of a pin, the ends of which are inserted into the bone omozgovoy channel and suturing of the wound at the middle and lower third of the forearm.

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