RU2267305C1 - Method for external fixation at treating acromial clavicular dislocations - Google Patents

Abstract

FIELD: medicine, orthopedics, traumatology.

SUBSTANCE: one needle with support area should be applied through acromial clavicular end in sagittal plane from the front backwards, another one - through acromial clavicular end, towards outwards against it, in counter direction, the third needle should be directed through acromial scapular process in sagittal plane in direction from the front backwards, the fourth one - parallel to the third needle, towards inside against it, in opposite direction, then needles should be fixed upon semicircular supports of Ilizarov's apparatus. After dislocation reposition semicircular supports should be rigidly connected to develop stable fixation and provide reliable fixation of acromial clavicular end in articular cavity of acromial scapular process in reset position that enables to conduct earlier functional therapy.

EFFECT: higher efficiency of external fixation.

6 dwg, 1 ex

Description

The invention relates to medicine, in particular to traumatology and orthopedics, and is intended to fix the acromial end of the clavicle during ruptures of the clavicular-acromial joint.

A known method of treating acromial dislocation of the clavicle with external transosseous osteosynthesis using a device for reposition and fixation of the acromial end of the clavicle [2, 3]. In this case, one spoke with a thrust pad is carried out through the acromial process of the scapula in the sagittal plane from front to back, the second spoke with a thrust pad is drawn through the acromial end of the clavicle in the sagittal plane in the direction from back to front. The sharp ends of the spokes are fixed in the distraction, and the shanks in simple spoke fixators. The third spoke is passed through the coracoid process in the direction from front to back and from the inside out. Knitting needles are fixed in the original bracket. Reposition of the dislocated end of the clavicle is carried out by moving the spokes along the distraction special fixators of a special design.

The disadvantages of this method of treatment of dislocations of the acromial end of the clavicle are:

- High risk of eruption of single knitting needles with thrust pads held through the clavicle and processes of the scapula, which occurs after pulling the spokes along the distraction special fixators, and, subsequently, after the onset of functional loads on the operated limb. The erupted spokes no longer have a supporting function, which leads to insufficiently rigid and stable fixation of the damaged segment in the apparatus, as well as trauma to the bones and soft tissues of the shoulder girdle with the risk of developing local inflammatory complications.

- Passing one of the spokes through the coracoid process of the scapula is associated with a risk of damage to the neurovascular bundle located in the vicinity of the coracoid process of the scapula along the inner edge m. coracobrahialis [4]. When carrying out the knitting needles, especially in people with a developed layer of subcutaneous fat, when it is difficult to use the coracoid process as an external guide, the neurovascular bundle may be damaged when the knitting needle deviates from the intended direction. When teething this spoke, it is also possible to pressure it on the elements of the neurovascular bundle.

- To carry out the reposition, distraction special fixators of a special design are needed, which are not included in the set of commercially available parts of the apparatus of G. A. Ilizarov.

To eliminate these shortcomings, we proposed a method for treating dislocations of the acromial end of the clavicle using an external fixation apparatus, which is completed from a standard set of parts of G.A. Ilizarov’s apparatus. When completing the apparatus, two semicircular arcs of the apparatus of G.A. Ilizarov and distraction rods are used as an external support, and four spokes with thrust pads are used as osteo-fixators. The needles are held in anatomically and functionally safe areas of the shoulder girdle. The first spoke with a thrust pad is held through the acromial end of the clavicle in the sagittal plane in the direction from back to front, the second is drawn through the acromial end of the clavicle outward from the previously installed spoke, parallel to it, in the direction opposite to it. Through the acromial process of the scapula, the third and fourth spokes with thrust pads parallel to the previously installed are held. The third spoke is held in the front to back direction, the fourth - inwards from the previously installed knitting needle, in the direction opposite to it. Then the spokes are attached in brackets to the brackets and are fixed in pairs on the semicircular supports of the apparatus of G.A. Ilizarov. By manipulating the semicircular support with the needles held through the acromial end of the clavicle, the dislocation is repositioned. After reposition of the dislocation, the semicircular supports are rigidly connected by three distraction rods. The spokes are pulled, and the apparatus is finally stabilized. If necessary, compression is carried out in the damage zone due to the convergence of the semicircular supports along the distraction connecting rods.

The general layout of the apparatus is shown in figure 1, where

1 - acromial end of the clavicle;

2 - acromial process of the scapula;

3 - a spoke with a thrust pad, conducted through the acromial end of the clavicle in the sagittal plane in the direction from front to back;

4 - a spoke with a thrust pad, conducted through the acromial end of the clavicle in the sagittal plane in the direction from rear to front;

5 - a spoke with a thrust pad, conducted through the acromial process of the scapula in the sagittal plane in the direction from front to back;

6 - a spoke with a thrust pad, conducted through the acromial process of the scapula in the sagittal plane in the direction from rear to front;

7 - a specifier;

8 - bracket;

9 - semicircular support apparatus G.A. Ilizarov;

10 - distraction rod.

The method is as follows. The patient is placed on the operating table on his back, a roller is placed between the shoulder blades. Under general intravenous anesthesia after treatment of the surgical field, a knitting needle (3) is inserted through the acromial end of the clavicle with a thrust pad in the sagittal plane from back to front, a second knitting needle (4) through the acromial end of the clavicle, parallel to the first knitting needle, outside of it, in the direction (front to back). Through the acromial process of the scapula, the third and fourth spokes are carried out with thrust pads parallel to the previously installed. The third knitting needle (5) is carried out in the front to back direction, the fourth knitting needle (6) is parallel to the third knitting needle, inward from it, in the direction opposite to it (rear to front). Then the spokes are fixed in the special fixators (7) to the brackets (8) and are fixed in pairs on the semicircular supports of the apparatus of G.A. Ilizarov (9). By manipulating the semicircular support with the needles held through the acromial end of the clavicle, the dislocation is repositioned. After reposition of the dislocation, the semi-ring supports are rigidly connected by three distraction rods (10). The spokes pull and carry out the final stabilization of the apparatus.

The immobilization period is 6-8 weeks. If necessary, the convergence of the semicircular supports along the distraction connecting rods create a metered compression in the damage zone. Functional treatment is carried out at the same time.

The use for reposition and fixation of dislocations of the acromial end of the clavicle as osseo-fixators of four knitting needles with thrust pads conducted through the acromial end of the clavicle and the acromial process of the scapula increases the rigidity and stability of fixation and reduces the risk of local inflammatory complications compared with the use of three-spoke fixation. Holding the spokes in pairs through the acromial end of the clavicle and the acromial process of the scapula reduces the risk of eruption of the spokes under the action of contact force loads by increasing the number of osteo-fixators, which increases the rigidity of the structure.

When implementing this method, the spokes are held through the acromial end of the clavicle and the acromial process of the scapula, which are clear, easily palpable external landmarks of the shoulder girdle, in the immediate vicinity of which large neurovascular formations do not pass [1].

Thus, the spokes are held in the neutral zone, which reduces the intraoperative risk of damage to important anatomical structures and makes surgery more safe.

With closed repositioning of the clavicle, it is necessary to create conditions for firm fixation of the clavicle in the articular cavity of the acromial process for better adaptation of the ends of torn ligaments and the most favorable course of reparative processes in the area of the damaged ligamentous apparatus. By converging the semicircular external supports along the connecting distraction rods, the repaired acromial end of the clavicle and the articular cavity of the acromial process of the scapula are brought closer together and additional compression forces are created in this area. This does not require special devices for reposition and fixation of the dislocated acromial end of the clavicle.

Example. Patient K., 26 years old, was admitted to the department of traumatology, on the fourth day after the injury. He was injured when accidentally falling onto an outstretched left arm. On examination: deformation in the area of the damaged left shoulder girdle due to the protrusion of the acromial end of the clavicle, pain on palpation of the left clavicular-acromial joint, positive symptom of the “key”, moderate restriction of movements in the left shoulder joint. The diagnosis of “Rupture of the left acromial-clavicular joint with a complete dislocation of the acromial end of the clavicle” on the radiograph is confirmed (figure 2, before treatment).

The operation was performed: "Closed reduction of dislocation of the acromial end of the left clavicle with fixation by its compression-distraction apparatus." In the position of the patient on the back, with a roller between the shoulder blades, under general intravenous anesthesia after treatment of the surgical field, a needle was inserted through the acromial end of the clavicle with a thrust pad in the sagittal plane in the direction from back to front, the second spoke through the acromial end of the clavicle, parallel to the first needle, out from her in the opposite direction. Through the acromial process of the scapula, the third and fourth spokes with thrust pads parallel to the previously installed are held. The third spoke is held in the sagittal plane in the direction from front to back, the fourth - parallel to the third spoke, inside of it, in the direction opposite to it. Then the spokes are fixed in the special fixators to the brackets and are fixed in pairs on the semicircular supports of the apparatus of G.A. Ilizarov. By manipulating the semicircular support with spokes drawn through the acromial end of the clavicle, a dislocation was repositioned. After reposition of the dislocation, the semicircular supports are rigidly connected by three distraction rods. Then the spokes were pulled and the apparatus was finally stabilized. Produced a control x-ray (figure 3, during the operation).

The postoperative period was uneventful, without complications. In the postoperative period, the approach of the semicircular supports along the distraction connecting rods created a dosed compression in the damage zone. Physiotherapy and therapeutic exercises were carried out. A general view of the patient during treatment is presented in figure 4. Throughout the entire period of fixation, the patient actively used the limb on the side of the injury (Fig. 5, during treatment)

1.5 months after the operation, the apparatus was dismantled. On the radiograph (Fig.6, after treatment) dislocation of the acromial end of the clavicle is eliminated.

Inspected after six months. There are no complaints. The anatomical and functional outcome is good. The function of the upper limb in the shoulder joint in full. He works in the specialty.

The proposed method of external fixation in the treatment of dislocations of the acromial end of the clavicle allows:

- reliably hold the acromial end of the clavicle in a repaired position, providing high rigidity and stability of fixation, and therefore, eliminate the risk of developing relaxation and local inflammatory complications;

- increase the safety of surgical intervention, reducing the risk of damage to neurovascular formations;

- create additional compression in the area of damaged clavicular-acromial joint for a more favorable course of reparative processes.

Information sources:

1. Ostroverkhov, G.E. Operative surgery and topographic anatomy / G.E. Ostroverkhov, Yu.M. Bomash, D.N. Lubotsky. - Kursk. Moscow: CJSC Litera, 1996. - 720 p.

2. Urazgildeev R.Z. Stable-functional osteosynthesis with external fixation devices for dislocations and fractures-dislocations of the acromial end of the clavicle: Abstract. dis ... cand. honey. sciences / R.Z. Urazgildeev; CITO them. N.N. Priorova. - Moscow, 1997 .-- 19 p.

3. Urazgildeev R.Z. Stable-functional osteosynthesis by the transosseous fixation apparatus for dislocations and fractures-dislocations of the acromial end of the clavicle / RZ Urazgildeev // Bulletin of Traumatology and Orthopedics. N.N. Priorova. - 1998. - No. 4. - S. 44-48.

4. Shevkunenko V.N. A short course of operative surgery with topographic anatomy / V.N. Shevkunenko - M .: Medgiz, 1947. - 567 p.

Claims (1)

The method of external fixation in the treatment of acromial dislocation of the clavicle, carried out by external transosseous osteosynthesis, including conducting in the sagittal plane of the knitting needle with a thrust pad through the acromial end of the clavicle back to front and the knitting needle with a thrust pad through the acromial process of the scapula in front to back direction, characterized in that it is additionally carried out a knitting needle with a thrust pad through the acromial end of the clavicle outward from the previously installed, in the direction opposite to it, and also hold the knitting needle with a thrust the platform through the acromial process of the scapula inward from the previously installed, in the direction opposite to it, and the spokes are parallel to each other.

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