RU2271733C2 - Method for predicting acute tissue hypertension syndrome at closed femoral fractures - Google Patents

Abstract

FIELD: medicine, traumatology, surgery.

SUBSTANCE: in patient being in horizontal position one should measure intra-tissue pressure with the help of acicular manometer in muscles of healthy femur and intra-tissue pressure in muscles of traumatized femur, separately in internal, anterior and posterior fascial channels, then values should be put into the formula. One should calculate the percentage against the difference of these values separately for internal, anterior and posterior fascial channels to diagnose acute tissue hypertension syndrome, at its increase up to 45% in internal, up to 40% in posterior and up to 35% in anterior fascial femoral channels. The innovation enables to establish tissue hypertension syndrome in the first stage of development and, thus, improve therapeutic results.

EFFECT: higher efficiency of diagnostics.

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Description

The invention relates to medicine, namely to diagnostic methods, and can be used in traumatologists and surgery for the operational diagnosis of acute tissue hypertension syndrome, as complications of femoral fractures.

Tissue hypertension syndrome is one of the most common complications of closed injuries of long tubular bones. In foreign literature, this pathological process is known as compartment syndrome and is defined as a condition in which increased interstitial pressure in a confined space leads to damage to neuromuscular structures located inside this space [1].

The development of acute tissue hypertension syndrome passes through two periods in which three stages are distinguished. The first period is functional changes: stage 1 (up to 24 hours) - local trigger irritation. The interstitial pressure is 55.64 ± 1.18 mm aq. Art. The arterial section of the microvasculature is narrowed, the venous is dilated, the diffusion surface is reduced. The coefficient of outflow and inflow 1: 2. Lymphatic vessels of loose fascia, subcutaneous tissue and collectors of dense fascia of the distal extremities are diffusely dilated, lymphatic stasis. Stage 2 (1-3 days) - compensatory-ischemic changes. The interstitial pressure is 74.20 ± 2.81 mm aq. Art. Reserve capillaries function. Venules are filled with shaped elements, extravasates appear. Lymphatic collectors of interested cases are blocked. The second period (over 3 days) includes stage 3 - degenerative-dystrophic changes. The interstitial pressure is 95.11 ± 1.12 mm aq. Art. Arterioles are convoluted, narrowed 2-3 times, venules - 1-1.5, fragmented. Lymphatic collectors are clearly expanded, lymph flow retrograde to the surface collateral.

So, the start of the pathogenesis of tissue hypertension syndrome is caused by the following causes of increased interstitial pressure: bleeding into confined spaces, local increase in capillary permeability, which is caused by fractures of long tubular bones, soft tissue crush, prolonged compression of the limb, post-ischemic edema that occurs after restoration of arterial blood flow. Further development of tissue hypertension syndrome is due to the cessation of venous outflow from muscles located in sealed fascial cases, which have high strength and elastic modulus with relatively small deformations. Iatrogenic factors contribute to the development of the compartment syndrome, namely circular soft and gypsum dressings, an excessively elevated position of the limb (above the level of the heart in a horizontal position). Late diagnosis and specialized medical care are the causes of the formation of myofascial pain syndromes observed in 70% of victims [2].

In the study of patent and scientific medical literature [1], the following methods were identified, used for a similar purpose, namely, the continuous infusion method, lobe and fetal catheters. A common disadvantage of these methods is the inability to perform dynamic monitoring of interstitial pressure in the affected segment. There is no data on the critical value of interstitial pressure, depending on the measurement method, which, along with the physical data, is an objective indication for fasciotomy.

A method for diagnosing decompensated extremity conditions during transosseous osteosynthesis [3] consists in determining the peak blood flow index and compliance of the leg muscles. In accordance with the methodology of the method with peak blood flow index values less than 3.3 rel. units and compliance less than 3.0.10-3 m / N diagnose the decompensated state of the muscles with acquired defects of the lower leg bones. Decompensated limb condition with peak blood flow index values of less than 1.3 rel. units and compliance less than 4.5.10-3 m / N is diagnosed with congenital defects of the leg bones. The method has the following disadvantages: for its implementation, it is necessary to have several diagnostic devices (electroplatismograph, myotonometer), the calculations are performed by a doctor, for the implementation of the method it is necessary to conduct a three-minute ischemic test and move the victim to the stomach, which excludes dynamic monitoring of the condition of the affected segment against the background of a general serious condition patient, the analogue is not adapted for the diagnosis of tissue hypertension syndrome in the thigh.

The prototype of the present invention is a method of invasive examination of interstitial pressure using a monitor "Stryker" REF 295-1 [4].

The disadvantage of this method is that as a result of an objective study, the traumatologist does not receive a reliable criterion for establishing indications for decompression fasciotomy in a single fascial bed of the thigh.

The objective of the invention is to improve the treatment of fractures of the femur by early diagnosis of tissue hypertension syndrome.

The problem is achieved by measuring the interstitial pressure in the muscles of a healthy and injured thigh, separately in each fascial bed, then calculating the percentage of the difference between these values and diagnosing acute tissue hypertension syndrome with its increase to 45% in the inner, up to 40% in the back and up to 35% in the anterior fasciotic femoral beds.

The method is as follows. The test is in the horizontal position, the needle gauge is measured interstitial pressure in the muscles of healthy femur (P ₁₎ and the interstitial pressure in the injured hip muscles, separately in the inner (R _2c), the front (F _2n) and posterior (P _2s) fastsilnyh beds, then values are substituted into the formula.

A percentage of the difference in these values is calculated separately for the internal (R _c ), front (R _n ) and posterior (R _c ) fascial beds and acute tissue hypertension syndrome is diagnosed, with its increase up to 45% in the internal, up to 40% in the back and up 35% in the anterior fascial femoral beds.

Using the proposed method is illustrated by the following examples.

Example 1

Patient N-ev G.A., 41 years old, medical history No. 1184, was admitted to the orthopedic and traumatological regional clinical hospital No. 1 of Rostov-on-Don on November 6, 2003, with complaints of pain in the left thigh and impaired support the inability to move independently. According to the patient, he was injured on November 4, 2003, when falling from a height of about 2 meters. When viewed in the front compartment: the left lower limb is pale in color, determined by severe, intense swelling of the soft tissues on the border of the upper and middle third of the thigh, deformation, pathological mobility. The pulsation of the popliteal artery is weakened. Hyposthesia on the back surface of the lower leg is determined. Active movements are sharply limited.

On the roentgenogram of the left thigh, an oblique fracture of the femur is determined at the border of the upper and third, with an angular displacement.

Based on clinical and instrumental data, the diagnosis was made: closed fracture of the femur on the left, acute tissue hypertension syndrome.

The patient was sent to the intensive care unit, where infusion therapy was started. A general clinical examination and diagnosis of tissue hypertension syndrome in an invasive manner were performed.

The percentage of the difference in interstitial pressure in all fascial beds of the left thigh is 45%.

In an emergency, under general anesthesia, a decompression fasciotomy of the internal, posterior and anterior fascial femoral beds was performed. Performed compression-distraction osteosynthesis. The postoperative period was uneventful, the wound healed by primary intention. Skin sutures were removed on day 12. The patient was discharged for outpatient treatment on the 19th day. In the distant period, consolidation of the fracture was observed after 3 months, full function in adjacent joints, absence of edema and pain in the left lower limb. Rehabilitation measures (physiotherapy, exercise therapy) were carried out. During the control examination after 4 months from the moment of injury, a complete restoration of the function of the left lower limb was noted. On the electromyogram of the muscles of the forearm there are no trigger zones.

Example 2

Patient Ch-in A.S., 50 years old, medical history No. 969, was admitted to the orthopedic and traumatology department of the regional clinical hospital No. 1 of Rostov-on-Don on 12/01/03 with a diagnosis of closed diaphyseal fracture of the right femur with offset.

He was injured in a road accident on November 26, 2003. He was treated before entering the CRH at the place of residence: an attempted closed reposition, a circular plaster cast to the hip joint with a back brace.

An X-ray examination determines an oblique fracture in the middle third of the femur on the right.

At the time of admission, varus deformity of the right thigh and widespread soft tissue edema are noted. On palpation, sharp pain and crepitus of bone fragments are noted. Pulsation of the popliteal artery is weak.

A general clinical examination and diagnosis of tissue hypertensive invasive method were performed. It was found that the difference in interstitial pressure in the inner fascial bed of the right thigh is 55%, in the anterior and posterior 45%.

Under general anesthesia, an emergency decompression fasciotomy of the inner, anterior and posterior fascial femoral beds was performed as an emergency, and compression-distraction osteosynthesis was performed.

During the patient’s repeated treatment on February 20, 2004, a slowdown in fracture consolidation was revealed radiologically, clinically and radiologically it occurred 5 months later.

When examining the patient 6 months after the operation, swelling of the soft tissues of the right lower limb is revealed. Palpation is determined by pain on the back-inner surface of the right thigh. Support for the right lower limb is impaired.

Using the method for the diagnosis of acute tissue hypertension syndrome in fractures of the femur allows you to establish tissue hypertension syndrome in the first phase of development and thereby improve treatment outcomes.

Bibliography

1. S. N. Rorabeck and N. M. McGree, Bulletin of 1996, No. 4, 2-5.

2. Liev A.A. Manual therapy of myofascial pain syndromes. Dneprkniga, Dnepropetrovsk, 1993.

3. Application for the grant of a patent of the Russian Federation for invention No. 99115525/14.

4. Important information: "Intra-Cjmpartmental Pressa monitor system"; Stryker® instruments 4100 East Milham Kalamazoo, Michigan (USA) 49001, 269-323-7700, 1-800-253-3210.

Claims (1)

A method for diagnosing acute tissue hypertension syndrome with closed fractures of the femur by invasive recording of interstitial pressure, characterized in that the interstitial pressure is measured in the muscles of a healthy and injured thigh, separately in each fascial bed, then the percentage of the difference of these values is calculated by the formula R = (P ₂ / P ₁ -1) × 100%, where P ₁ is the interstitial pressure in the muscles of a healthy thigh, P ₂ is the interstitial pressure in the muscles of an injured thigh, and acute tissue hypertension syndrome is diagnosed m with its increase up to 45% in the inner, up to 40% in the back and up to 35% in the front fascial bed of the thigh.