RU2231322C1 - Method for fixing fractured bone fragments in the cases of depressed fracture - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves making a not more than 2 cm deep incision in frontal area from a point belonging to fracture edge line projected upon skin in superciliary area. Front bone area adjacent to fracture zone is skeletted in the incision area. Kirschner wire is conducted through soft tissues of front above the fractured bone fragments near the periosteum in parallel to a line tangential to upper orbit edges. The Kirschner wire is bent as arch corresponding to front bone curvature at the fracture place. Its length is greater than depressed area length.

EFFECT: enhanced effectiveness of surgical treatment; reduced risk of traumatic complications; accelerated bone adhesion process.

5 dwg

Description

The method relates to medicine and can be used in maxillofacial surgery, ENT surgery, neurosurgery.

Depressed fractures of the anterior wall of the frontal sinus are found according to the literature [1] and our observations in about 1% of cases from injuries of the nose and paranasal sinuses. Depressed fractures of the anterior wall of the frontal sinus are always comminuted, fragments are small in size and thickness. Therefore, in the treatment of this type of traumatic injury after reposition of the fragments, they cannot be held in the correct position on their own, and you have to resort to their additional fixation - osteosynthesis, and with the formation of extensive bone defects, to plastic the resulting defect of various types with transplants. The described methods offer a wide skeletonization of bone fragments, their reposition and open osteosynthesis with wire sutures, mini-plates, replacement of defects of the front wall of the frontal sinus of various types by transplants after removal of bone fragments [2, 3, 4].

Closest to the proposed method is the method described by P.Z. Arzhantsev and V.P. Ippolitov [3]. In accordance with it, an incision is made in the frontal region. Bone fragments skeletonize. Boron creates a trepanation hole in the frontal sinus away from the fracture and perforations in all bone fragments and fasten them with a chrome catgut. Then the fragments are repaired by the elevator through the trepanation hole and fixed with four wire sutures to the frontal bone. In the frontal sinus, through the upper nasal passage and the anterior section of the ethmoid bone, a bisexual chlorovinyl tube is inserted through which the frontal sinus is washed in the postoperative period and antibiotics are administered. The wound is sutured in layers.

The disadvantages of this method is the need for a fairly large incision in the frontal region, wide skeletonization of bone fragments, the need for an additional naso-antrum anastomosis.

The claimed invention solves the problem of creating a less traumatic way of securing fragments with pressed fractures of the anterior wall of the frontal sinus.

The technical result of the invention is to reduce trauma in the treatment of fractures of the anterior wall of the frontal sinus.

This technical result is achieved by the fact that in the treatment of impressed fractures of the anterior wall of the frontal sinus, an incision is made up to 2 cm long from the point located on the line of projection of the fracture edge onto the skin in the superciliary region, a portion of the frontal bone adjacent to the fracture zone at the incision site is skeletonized after why in this section a trepanation hole is created in the frontal sinus, through which reposition of fragments is made, then from the place of the cut through the soft tissues of the frontal region above the fragments, near the periosteum, parallel to the tangent When drawn to the upper edges of the orbits, a Kirschner needle is bent along an arc corresponding to the bend of the frontal bone, the length of which is 2-3 cm longer than the length of the depressed area.

The method is as follows.

After a comprehensive examination of the patient, assessment of his condition, surgical treatment is performed together with a neurosurgeon, an ophthalmologist. The projection of the edge of the depressed fracture on the skin in the area above the eyebrow is determined. Here, a soft tissue incision is made to the bone 1.5-2 cm long. A small portion of the bone is skeletonized, which is under the wound, but not displaced fragments. A small trepanation hole, with a diameter of not more than 1 cm, is made in an intact section of the front wall of the frontal sinus next to the fracture gap with bone nippers or a milling cutter, using a drill or a rotor from the neurosurgical set. Through the indicated trepanation hole, blood clots from the sinus are washed and, if necessary, revision of the sinus cavity with an endoscope (Fig. 1).

In the absence of indications for a wide revision of the frontal sinus (comminuted fracture of the posterior wall of the frontal sinus, polyposis, etc.), the reposition of displaced fragments of the anterior wall of the frontal sinus is performed by the elevator (Fig. 2). For this, you can also use a curettage spoon or a curved clamp. Then they are additionally fixed.

Fixation of fragments of the anterior wall of the frontal sinus is performed according to a closed technique using a Kirchner needle (1.5 mm in diameter) from a trauma kit curved along an arc corresponding to the curvature of the frontal bone. The length of the needle fragment should be 2-3 cm longer than the length of the depressed portion of the anterior wall of the frontal sinus. The needle through the wound due to the incision is carried out in the soft tissues of the frontal region above the fragments as close as possible to the periosteum, parallel to the tangent drawn to the upper edges of the orbits. It is carried out so that its ends stand outside the fracture area and are located above the intact bone. Given that the bone fragments, when performing this operation, do not exfoliate from the periosteum, they are quite reliably fixed in a given position (Fig. 3). The elasticity of the spokes prevents the displacement of fragments in the postoperative period under the influence of external factors - careless behavior of the patient or during careless dressings. Additional fixation of the spoke to the frontal bone is not required or it can be fixed in the area of the wound with a nylon seam. A tubular drainage is left in the indicated trepanation opening, through which the frontal sinus is washed in the postoperative period and antibiotics and other drugs are administered. The wound is sutured in layers. Hemostasis during the operation is carried out according to the generally accepted technique (usually using an electrocoagulator). Stitches are applied to the skin. Drainage is removed after a few days, as the outflow from the sinus through the natural naso-antral fistula is restored. A month after the operation, after the consolidation of the fragments, on an outpatient basis, under local anesthesia, the latter is removed through a small puncture incision in the area of the tip of the spoke. The needle is reasonably well felt in the soft tissues, so its search and removal does not cause any difficulties.

Surgical intervention with the proposed method is best carried out under general anesthesia, since there is the possibility of palpation control over the reposition of fragments of the anterior wall of the frontal sinus. When conducting local anesthesia, this possibility is very difficult due to an increase in the volume of soft tissues due to their injection with an anesthetic solution.

The positive aspects of this operation are obvious. First: the operation is less traumatic. There is no "wide" access to fragments, which is necessary for conventional osteosynthesis with miniplates, wire or other suture between fragments. Secondly: due to the fact that the operation does not require wide access to fragments, the cosmeticity necessary for face surgery is achieved. Thirdly, due to the fact that the fragments do not skeletonize and retain an intimate connection with the periosteum, and the front wall of the frontal sinus receives food mainly through it, the possibility of osteolysis is prevented and the process of adhesion is accelerated. Fourth: in the absence of pathological changes in the frontal sinus (polyposis, chronic inflammation of the mucous membrane), there is no need to apply additional naso-antral anastomosis through the anterior cells of the ethmoid bone, which is usually recommended for operations on the frontal sinus. This again reduces the morbidity and duration of surgery.

If necessary, a wide revision of the frontal sinus is a coronary incision according to Zueter. The frontal bone is skeletonized to the upper edges of the orbits. But in the area of the edges of the fracture, the frontal sinus is opened. Fragments of the anterior wall of the frontal sinus retain connection with the periosteum and, together with the flap, carefully recline towards the face. Thus, widespread access to all parts of the frontal sinus is created. After surgery in the frontal sinus, its rehabilitation and, if necessary, application or filling of the naso-antral fistula, which is dictated by the conditions of the operation, the fragments of the anterior wall of the frontal sinus are repositioned and secured with a knitting needle inside the flap according to the method described above. Fragments along with a flap fit into place. The wound is drained and sutured.

The claimed method was operated on 9 people. No significant complications were noted.

Example. Patient V., born in 1977, was admitted to the ENT department of the City Emergency Hospital in Cheboksary on March 13, 2002. He was injured 5 days before - a blow to the forehead with a bottle. Examined by a neurosurgeon, ENT doctor. After the examination, the diagnosis was made: an impressed comminuted fracture of the anterior wall of the frontal sinus on the right. On March 14, 2002, under intravenous anesthesia, an operation was performed to reposition and fix fragments of the anterior wall of the frontal sinus according to the proposed method with sinus drainage through a trepanation hole. Four days later, sinus drainage was removed. The patient was discharged for outpatient aftercare in a satisfactory condition on March 20, 2002. A month later, after a follow-up examination, the needles were removed on an outpatient basis. As illustrations, radiographs of the patient after surgery are shown (FIGS. 4-5).

Sources of information

1. Enin I.P., Karpov I.N., Tumartsov I.N., Pavlov A.S., Plyaskin V.G., Sivovalova N.A. Emergency care for injuries to the nose and paranasal sinuses in the conditions of insurance medicine / Materials of the XVI Congress of Otorhinolaryngologists of the Russian Federation - St. Petersburg: "Ria-AMI", 2001, p.574-573.

2. Otolaryngology / Ed. I.B. Soldatova and V.R. Hoffmann. - St. Petersburg., 2000 .-- 472 p. (S.237-238).

3. Injuries to the maxillofacial region / Ed. N.M. Alexandrova, P.Z. Arzhantseva. - M.: Medicine, 1986.- 448 p. (S.271-272).

4. Guide to surgical dentistry and maxillofacial surgery: in 2 volumes. T. 2 / Ed. V.M. Bezrukova, T.G. Robustova. - Ed. 2nd. - M.: Medicine, 2000 .-- 488 p. (S.291-299).

Claims (1)

A method of treating impressed fractures of the anterior wall of the frontal sinus, in which an incision is made in the frontal region, a portion of the frontal bone is skeletonized, after which a trepanation hole is created in this frontal sinus through which reproduction of fragments of its anterior wall is made, characterized in that the incision is in the frontal areas are performed from a point located on the line of projection of the edge of the fracture on the skin in the superciliary region, and the size of the incision does not exceed 2 cm, and for skeletonization, select the area adjacent to the fracture zone in m section of the incision, and then from the incision through the soft tissues of the frontal region above the fragments, near the periosteum, parallel to the tangent to the upper edges of the orbits, a Kirschner needle is bent along an arc corresponding to the bend of the frontal bone at the fracture, which is 2-3 cm long more than the length of the depressed area.

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