RU2242187C2 - Method for treating the cases of proximal humerus end fracture - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves preliminarily treating transplant manufactured as unclosed tube. The transplant is introduced into the medullary canal and arranged with its unclosed part turned towards posterior surface of the humerus. The proximal and distal ends are fixed with screws. The screws are introduced in planes orthogonal to each other at an angle of 45° to the unclosed part of the transplant.

EFFECT: tight adjacency to medullary canal walls; accelerated blood vessel proliferation.

3 dwg

Description

The present invention relates to medicine, namely to traumatology, and can be used for the surgical treatment of fractures (including comminuted fractures) and false joints of the proximal humerus.

A known method of osteosynthesis of fractures of the proximal end of the humerus, proposed by A. P. Makarov [1]. The author used a homograft with a length of about 10-12 centimeters prepared from the upper half of the fibula with its head (or from the lower half of this bone with an ankle) in the treatment of patients with fractures and fractures of the surgical neck of the humerus. The essence of the known method is as follows: the end of the diaphyseal part of the graft is slightly thinned, giving it a slightly conical shape for insertion into the bone marrow canal of the distal fragment of the shoulder to a depth of 7-9 cm. From the head or ankle of the fibula after treatment (release from cartilage, periosteum) a thickened end of the graft is round-oblong in shape with a spongy bone structure, which, during osteosynthesis, is inserted into a nest in the head made in advance from the side of the fracture plane the humerus is about 2.5-3 cm deep and about 2-2.5 cm in diameter, i.e. in accordance with the shape, size and bone structure of the thickened end of the graft. The operated limb is fixed with a thoracobrachial plaster cast for an average of 1.5-2 months.

Closest to the proposed is a method of intramedullary use of a fibula transplant for osteosynthesis of the humerus, described by T.W. Wright et al. [2]. The authors use an autograft of the fibula diaphysis, iliac crest, or a frozen allograft, placing it in the bone marrow channel of the humerus as an addition to fixation with a compression plate to improve the fixation strength of screws passing through 4 or 3 (when using a chip of the fibula) of the cortical layer while the ends of the plate and the graft are placed at different levels to reduce stress concentration.

However, the known methods have significant disadvantages, namely:

- instability of osteosynthesis with an autograft, which necessitated external immobilization with a plaster cast, which does not allow early functional treatment to begin;

- fixation with a bone plate requires additional detachment of soft tissues for its use, which in conditions of limited blood supply to the proximal humerus negatively affects reparative processes;

- known methods can be limitedly used for comminuted fractures.

Based on the current level of technology for the treatment of fractures of the proximal end of the humerus, the task was set: to increase the effectiveness of the treatment of fractures of the proximal end of the humerus by maintaining extraossal blood supply to the proximal fragment of the humerus, creating conditions for faster recovery of intramedullary blood supply, as well as increasing the universality of the treatment technology, then there is a provision for stable fixation for any fracture of the neck and head of the shoulder, regardless of the type of ringed fracture and the degree of osteoporosis.

The problem is solved as follows.

A method for treating fractures of the proximal end of the humerus includes reposition of the fracture, procurement of an autograft from the fibula diaphysis in accordance with the dimensions of the reamed bone marrow canal, and osteosynthesis with an autograft. New in solving this problem is that the autograft is pre-treated in the form of an open tube, then inserted into the bone marrow canal and placed with the open part to the posterior surface of the humerus. After that, the proximal and distal ends of the autograft are fixed with screws, while the screws are carried out in mutually perpendicular planes at an angle of 45 degrees to the open part of the autograft.

Explain the salient features of the proposed method.

Pretreatment of the fibula autograft in the form of an open tube, i.e. the presence of a slot along the entire length of the graft prevents the stress concentration at the upper end, especially during torsion, and ensures uniform distribution of stress along the entire length of the graft due to its elastic and plastic deformation, and also ensures its better correspondence to the shape of the medullary channel (more tight fit of the graft to walls of the bone marrow cavity), which in turn leads to increased stability of fixation and faster germination of blood vessels in the autograft. Placement of the open part to the posterior surface of the humerus is necessary for more rapid vascularization of the graft and fracture site, as topographically, the entry site of the diaphyseal artery in the upper third of the humerus is most often located on the posterior surface of the humerus [3].

Subsequent screw fixation of the proximal and distal ends of the autograft, as well as holding screws in mutually perpendicular planes ensures the stability of osteosynthesis for torsion and tension, and holding the screws at an angle of 45 degrees to the open part of the autograft allows screws to pass through 4 cortical layers (2 cortical layers of the humerus and 2 - fibular), which allows to achieve the formation of additional fixation points of the threaded part of the screws at the entrance and exit through cortical transplantation, which significantly increases the stability of fixation of screws (which is especially important when reducing bone quality). With the comminuted nature of the fracture of the humerus, additional screws can be used to fix the fragments through the graft in the most favorable plane and direction to create compression between the fragments.

The patent studies on subclasses A 61 B 17/56 and the analysis of scientific and medical information reflecting the current level of treatment for fractures of the proximal end of the humerus did not reveal technologies identical to the proposed one. Thus, the proposed method of treatment is new.

The interconnection and interaction of the essential methods of the proposed method ensures the achievement of a new technological medical result in solving the problem, namely, increasing the efficiency of treatment of fractures of the proximal end of the humerus by maintaining extraossal blood supply to the proximal fragment of the humerus, creating conditions for a more rapid recovery of intramedullary blood supply, as well as increasing universality of treatment technology, i.e. ensuring stable fixation and with any fracture of the neck and head of the shoulder, regardless of the type of comminuted fracture and the degree of osteoporosis. Thus, the proposed technical solution has an inventive step.

The proposed method for the treatment of fractures of the proximal end of the humerus is industrially applicable in the field of practical health care, as it can be reproduced repeatedly and does not require the use of exceptional means for implementation.

The essence of the proposed method is as follows.

From the access to a length of 5 cm along the fibers of the deltoid muscle in its upper part at the junction of the anterior and middle third, the tendon of the supraspinatus muscle is dissected along the fibers, in the region of a large tubercle at a distance of 0.5 cm from the outer part of the cartilage of the head of the humerus (at the border of the cartilage tendon part of the head of the humerus) open the bone marrow channel of the proximal fragment of the humerus. Drilling of the marrow canal is carried out in the distal direction up to a diameter of 10-14 mm, depending on the individual characteristics and the estimated diameter of the marrow canal of the distal fragment in the upper third. At the same time, a subperiosteal autograft of the fibula diaphysis is made from two approaches of 2 cm according to the method described by AP Barabash [4], with a length of approximately 1/2 the length of the humerus, which is an average of 15 cm. The selected graft length less than 50% of the length of the fibula, which does not affect the function of the lower leg in the postoperative period, but at the same time it is sufficient to perform osteosynthesis of a fracture of the humerus and prevent the concentration of stress arising on the con fragments and autograft. Also, the selected autograft length is due to the anatomical structure of the bone marrow canal of the humerus, which has a narrowing in its diaphyseal part, starting approximately from the middle of the diaphysis, and therefore the distance equal to about half is considered to be the optimal length of the intraosseous fixator for osteosynthesis of fractures of the proximal end of the humerus its length, which is on average equal to 30 cm. In subjects with a wider and shorter or narrower and longer bone marrow canal of the humerus lzovan longer or shorter, respectively, autograft, which is easy to achieve, because the length and diameter of the fibula, as a rule, are directly proportional to the length and diameter of other bones, including the humerus. An autograft is treated with an electric milling cutter along the diameter of the marrow canal. Considering the fact that the fibula at the transverse section, as a rule, has a shape close to an irregular triangle, the transplant without special effort is shaped like an “open tube” by cutting the most acute angle. To control the diameter of the graft throughout use a plate with calibrated holes, for example from a standard set of AO for intramedullary osteosynthesis.

Closed reposition of the fracture and temporary intramedullary fixation with a 2 mm diameter spoke are performed. The standing of the fragments and the position of the spokes are controlled using Rg-graphy in two projections. On the spoke used as a guide, antegrade osteosynthesis is performed with the treated autograft, having its open part to the posterior surface of the humerus. In this case, the graft is a “cannulated” fixator, where the axial opening is the bone marrow canal of the fibula. The graft is immersed without standing above the cortical layer of the shoulder head (prevention of impingement syndrome), because no need to remove the structure afterwards. Blocking of the proximal fragment with one or two threaded screws along the entire length (the choice is caused by the appearance of additional fixation points of the screws in the graft and, as a result, the emergence of angular stability of the screws, which is especially important when the bone quality is reduced due to the patient's age or period after the injury). At the time of proximal blocking, additional fixation of fragments of the proximal humerus to the autograft is possible using compression screws extending in any direction relative to the axis of the humerus.

Tight contact along the ulnar process in the direction of the long axis of the humerus or using the contractor achieves tight contact and simultaneous compression between the distal and proximal fragments and performs distal blocking with 1-2 screws located in mutually perpendicular planes at an angle of 45 degrees to the open part of the autograft.

In case of failure of the closed reposition, open adaptation of the fragments is performed using one of the known approaches. Additional immobilization in the postoperative period is not carried out, the patient begins early movements in the shoulder joint.

The essence of the proposed method for the treatment of fractures of the proximal end of the humerus is illustrated by a clinical example.

A 54-year-old patient N. (a plasterer-painter) was admitted to the clinic of the State Center for Surgery of the Oncological Center of the Specialized Medical Center SB RAMS on the 5th day after the injury.

Diagnosis: Closed comminuted fracture of the surgical neck of the left humerus with displacement. On Rg-gram: The violation of the integrity of the upper third of the humerus is determined. The contours of the ends of the fragments are even, clear. Width offset 3.5 cm inward and 1.5 cm proximally. On the outer surface of the proximal fragment is an additional bone fragment of 1.5 × 1 cm. Regional osteoporosis (figure 1).

From the anamnesis: Injury on 01/26/02., Domestic, got into an accident (was hit by a car), was taken to the hospital on duty, where after the examination the block of the fracture site was performed, a plaster cast like Coellwell was imposed, refused to be admitted to the hospital, 01/30/02. appealed to the above clinic, hospitalized.

02/04/02 operation performed. From the antegrade access 4 cm long along the deltoid muscle fibers in the upper part at the junction of the anterior and middle third, the subacromial sac was partially removed, the supraspinatus tendon is dissected along the fibers, in the region of a large tubercle at a distance of 0.5 cm from the outer part of the humeral head cartilage the bone marrow canal of the humerus was opened. Drilling of the marrow canal in the distal direction up to a diameter of 12 mm was performed. At the same time, a subperiosteal autograft of the fibula diaphysis was taken from the tibia 15 cm long from two accesses 2 cm long. The autograft was processed using an electric cutter in the form of an “open tube” up to a diameter of 12 mm. Closed reposition of the fracture and temporary intramedullary fixation with a 2 mm diameter spoke were performed. The standing of the fragments and the position of the spokes were controlled using Rg-graphy in two projections. On the spoke used as a guide, antegrade osteosynthesis was performed with a processed autograft, which has an open part to the posterior surface of the humerus. Repeated Rg-graphy: standing fragments satisfactory. The proximal fragment of the humerus was blocked with two screws, from which it was drawn outside the inside and behind the front anteriorly at an angle of 45 degrees. to the back surface of the humerus, the second - from the inside out and from the bottom up, fixing an additional bone fragment. Light striking along the ulnar process - in the direction of the long axis of the humerus, tight contact and simultaneous compression between the fragments of the humerus are achieved. The distal fragment of the humerus was blocked with one screw located outside the inside and front to back at an angle of 45 degrees to the “open” part of the autograft (posterior surface of the humerus), allowing the screw to pass through 4 cortical layers. Stitches for wounds.

Rg-control 02/05/02 (figure 2): the integrity of the humerus is restored, the displacement along the length is eliminated, the width is reduced to 0.5 cm. In the projection of the bone marrow canal of the proximal humerus, a bone graft of 1 × 15 cm is determined, fixed with 3 screws. The bone structure is heterogeneous. Regional osteoporosis.

In the postoperative period, additional external immobilization was not carried out. An early functional treatment has begun (physical therapy for the shoulder joint, physiotherapy). Discharged for outpatient treatment on the 10th day after surgery. The seams are removed.

He started to work in the specialty 3 months after the operation. At the control examination after 6 months from the moment of surgery: no complaints, movement in the shoulder joint in full, on the control Rg-gram (figure 3): signs of fracture consolidation, pronounced periosteal regenerate. Signs of bone autologous graft reconstruction.

Thus, the proposed “Method for the treatment of fractures of the proximal end of the humerus” in comparison with other known technologies allows you to:

- perform stable-functional osteosynthesis of almost any, including a multi-fragmented fracture of the neck and head of the humerus;

- to provide reliable axial and anti-lateral compression of fragments of the humerus;

- increase the reliability of osteosynthesis in conditions of osteoporosis due to the emergence of additional fixation points of the screws in the graft (the passage of screws through 4 cortical layers) and, as a result, the reduction of the effect of “tearing” the screw;

- to reduce, compared with the prototype and analogues, the damaging effect of the retainer on the head of the humerus and surrounding soft tissue;

- provides the possibility of closed osteosynthesis;

- create conditions for improving blood circulation due to the absence of the osseous part of the fixative in the fracture zone, as well as the metal intraosseous fixative, which interfere with the germination of blood vessels;

- to avoid additional trauma, as there is no need to remove the retainer after consolidation of the fracture.

Sources of information

1. Makarov A.P. Intramedullary osteosynthesis with a homograft for complex and chronic fractures of the surgical neck of the humerus: Abstract. dis. Doct. honey. sciences. - Leningrad, 1972. - S.18-20.

2. Wright T.W., Miller G.J., Vander Griend R.A., Wheeler D., Dell P.C. Reconstruction of the humerus with an intramedullary fibular graft. A clinical and biomechanical study // J. Bon & Joint Surg. [Br] - 1993. - 75-B. - P. 804-807.

3. Anserov N.I. The arterial system of the human skeleton // Anatomical and surgical collection. - 1939. - Issue. 11. - S. 73-76.

4. RF patent No. 216296, MKI A 61 B 17/56, “Method for taking an autograft for bone autoplasty”. - 2001. - Bull. No. 13. / A.P. Barabash, A.A. Barabash, M.E. Puseva.

Claims (1)

A method for treating fractures of the proximal end of the humerus, including reposition of the fracture, procurement of an autograft from the fibula diaphysis in accordance with the dimensions of the broadened marrow canal and osteosynthesis with an autograft, characterized in that the autograft is pretreated in the form of an open tube, then inserted into the bone marrow canal and place the autograft with an open part to the posterior surface of the humerus, after which the proximal and distal ends of the auto are fixed with screws ransplantata, the screws carried in mutually perpendicular planes at 45 ° to an open portion of autograft.

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