RU2278626C2 - Method for mini-invasive costal fixation in case of multiple and floating fractures - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: one should apply a needle due to puncture-type technique beyond the area of traumatized soft tissues, subfascially, being above floating fracture, apply pericostal sutures onto stable fragments and a floating segment by fixing them to the needle along with simultaneous reposition of fragments. Operation should be carried out at thoracoscopy. The innovation enables to decrease traumatism of interference, remove intra-pulmonary and intra-pleural complications and provide earlier activation in patients.

EFFECT: higher efficiency.

2 cl, 2 dwg, 2 ex

Description

This invention relates to medicine, in particular to surgery, and is a method of restoring the carcass of the chest during multiple and floating fractures by minimally invasive fixation of costal fragments.

Until the 60s of the last century, the main methods of stabilizing the rib cage were the external traction of the floatation segment and pressure dressings. In the 1960s and 1980s, various methods of operative fixation of ribs were actively developed and applied. The most widely used method proposed by R. Judet in 1973. Fixation is carried out using special metal plates with curved edges (Judetplates), attached to the fragments of the ribs with screws (Lardinois D., Krueger T., Dusmet M., Ghisletta N., Gugger M., Ris H.-B. Pulmonary function testing after operative stabilization of the chest wall for flail chest // Eur. J. Cardiothorac. Surg. - 2001. - Vol.20. - P.496-501; Tanaka H., Yukioka T., Yamaguti Y., Shimizu S., Goto H., Matsuda H., Shimazaki S. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients // J. Trauma. - 2002. - Vol. 52. - No. 4 . - P.727-732). A large number of modifications of this method and its intramedullary analogs were later proposed. The method of fixation with braces also refers to the osseous fixation of rib fractures. Operations of osseous and intramedullary fixation of the ribs are characterized by great trauma due to the need to isolate the ribs, and access is via injured soft tissues, which creates conditions for suppuration of postoperative wounds, phlegmon of the chest wall.

With extra focal fixation, the ribs do not stand out from the injured tissues. This type of stabilization includes: subcutaneous fixation with synthetic plates; bringing ligatures under the fragments or stitching of the muscles of the chest wall with fixation to a plastic plate located on the skin along the rib; summing up the ligature under the sternum and ribs with subsequent fixation to special external fixation devices; skeletal traction and the use of external fixation devices; trans and periosteal fixation with polymer threads; subperiosteal conduction of spokes over the "rib valve" and further external traction. The closest is the method of fixation of fractures by bringing ligatures under the fragments with their fixation to the plate located on the skin along the rib (A.S. 938948 A 61, B 17/00. The method of fixation of fragments of the ribs with multiple and segmental fractures / B.S. Saltanov, H. Dzhumbaev (USSR) - No. 2507205 / 28-13. - Application. July 14, 07. Publish. 06/30/82. Bull. No. 24. - 6 pp .; Maslov V.I., Takhtamysh M.A. , Kretov A.I. Multiple double fractures of ribs with flotation of the chest wall // Surgery. - 2000.- No. 4). With this method, the tire is fixed to the skin for a long time, which can cause soft tissue necrosis from the pressure of the plates. These methods involve ligatures without vision control, which creates a high risk of damage to internal organs and does not make it possible to eliminate intrapleural complications that often complicate this type of injury. External traction methods also have a number of significant drawbacks - insufficient fixation, infection of rods, pressure sores from panels, inability to activate the patient, leading to the development of hypostatic pneumonia.

The emergence of modern breathing apparatus made it possible to carry out internal pneumatic stabilization of floating rib fractures (RPF) by means of prolonged mechanical ventilation with positive expiratory pressure (PEEP), supplemented by drainage of the pleural cavities with hemopneumothorax, adequate pain relief, and rehabilitation of the tracheobronchial tree and complex Therapies (Carpintero JL, Rodriguez Diez A., Ruiz Elvira MJ, Benitez JA, Perez Rielo A. Methods of management of flail chest // Intensive Care Med. - 1980. - Vol.6. - No. 4. - P. 217- 221; Velmahos GC, Vassiliu P., Chan LS, Murray JA, Beme TV, Demetriades D. I nfluence of flail chest on outcome among Berne TV, Demetriades D. Influence of flail chest on outcome among patients with severe thoracic cage trauma // Int. Surg. - 2002. - Vol.87. - No. 4. - P.240-244 ) However, this method also has several disadvantages. The consolidation of a rib fracture with the formation of primary bone callus starts from the 14th day, which requires a long mechanical ventilation. Prolonged mechanical ventilation is characterized by a high incidence of ventilator-associated pneumonia. Complications associated with prolonged intubation of the trachea exacerbate respiratory disorders that develop in the victims. Another disadvantage of this method is the incomplete immobilization of rib fractures due to the preservation of the mobility of the floating segment, which also increases the time of internal pneumatic stabilization.

Thus, the existing surgical techniques for fixation of the lateral fibroids are characterized by great trauma and frequent purulent-inflammatory complications; methods of cutaneous fixation with plates are characterized by a high risk of additional damage to internal organs, necrosis of soft tissues, and also do not make it possible to eliminate intrapleural complications; external traction techniques are characterized by a high risk of infection of cravings, soft tissues of the chest wall and the development of osteomyelitis, and also complicate the early activation of the patient; long-term mechanical ventilation is characterized by a high frequency of bronchopulmonary inflammatory complications.

The objective of the invention is the minimally invasive stabilization of floating rib fractures without incisions of injured soft tissues with the possibility of simultaneous elimination of intrapleural complications.

The problem is solved by the fact that by means of a puncture method outside the zone of injured soft tissues, subfascial, over a floating fracture, a needle is inserted, then pericostal sutures are placed on stable fragments and a floating segment, fixing them to the needle with simultaneous reposition of fragments, and the operation is performed with thoracoscopy.

The method is carried out in the following way. A thoracoscopy is performed on a patient by a standard technique. The trocar is administered outside the fracture zone. After the audit of the pleural cavity, the necessary manipulations are performed to eliminate the intrapulmonary and intrapleural complications of the injury: hemostasis, suturing of lung wounds and diaphragm, sanitation of the pleural cavity. The most mobile floating segments and the fragments of ribs that protrude into the pleural cavity are determined, which must be fixed. 3 cm away from the fracture lines, with the help of a stylet needle or other instrument, pericostal sutures are applied to stable segments and both ends of the floating segment under the control of a thoracoscope. The fragments are repositioned by pulling on the bone holders, after which, through a skin incision 1–2 mm long, located in the center of the stable segment of the rib, 3-5 cm from the fracture line, puncture the knitting needle into the subfascial space. When the spokes come into contact with a stable segment of the ribs, the spokes are tilted for further advancement along the rib surface, and the spokes are located in soft tissues between the rib and the pericostal suture (Fig. 1).

Figure 1 shows the relative position of the spokes, seam and ribs (cross section).

The spoke is fixed to stable segments, after which the flotation segment is fixed to the spoke, tightening the pericostally imposed sutures (figure 2). In the same way carry out the fixation of the floating segments of other ribs. The needles are removed after the formation of bone marrow, after 4-5 weeks.

In figure 2. A schematic representation of the fixation of a flotation fracture of the ribs is shown.

Clinical example:

1) Patient Khrapov Yu.A. entered the Central Institute of Traumatology and Orthopedics. N.N. Priorova (CITO) 02/10/03 after a car accident. Diagnosis: Severe combined trauma, closed chest injury, floating fracture of 6-7 ribs (from the anterior to the posterior axillary line), fracture of 5 and 8 ribs in the anterior axillary line, hemopneumothorax. Closed fracture of the right thigh. Urgently, the patient underwent osteosynthesis of the right thigh. 02.21.03 the patient underwent video-assisted mini-thoracotomy, evacuation of coagulated hemothorax, closure of a lung rupture, fixation of a floating fracture with Kirschner spokes according to the proposed technique under the control of thoracoscopy, drainage of the pleural cavity. The spokes are held in subfascial space in the form of the letter V along the entire floating segment with a 4 cm fit on the front and rear stable fragments of the 6th and 7th ribs. The knitting needles are fixed to stable fragments with 3 stitches using a Dexon No. 1 double thread held by a stylet needle under the control of thoracoscopy. The floatation fragment was repositioned and fixed to the knitting needles with 4 stitches using a Dexon No. 1 double thread, carried out with a stylet needle under the control of thoracoscopy. The postoperative period was uneventful. On the 3rd day after removal of drainage, the patient is allowed to get out of bed. After removing the spokes 42 days after surgery, the fragments are stable.

2) Patient Romashchenko A.N. 37 years old was admitted to the CITO on 06/11/03 with a diagnosis of: Multiple floating rib fractures on both sides with a displacement, large hemothorax on the right, acute respiratory failure, shock 2-3 tbsp. Abrasions of the face, limbs. Medical history: injured in a traffic accident on June 7 in the city of Klin, taken to the Klin city hospital in serious condition due to respiratory failure. Conducted antishock and infusion therapy. The ambulance brigade was delivered to the CITO on 11.06.03. Upon admission, the condition is serious, due to flotation of the sternum and anterior segments of all ribs with retraction of the sternum and paradoxical breathing, severe respiratory failure. On Rg-grams, fractures of the 2nd - 6th ribs on the right and from the 3rd to 6th on the left are determined. Fractures were localized along the middle clavicular lines on both sides and along the anterior axillary line on the right. On 11.06.03, the patient underwent a right-sided video-assisted mini-thoracotomy with evacuation of hematorex and fixation of the floating sternocostal segment according to the proposed method; thoracoscopy on the left with the evacuation of hemothorax, fixation of the floating sternocostal segment. At the same time, three knitting needles were held on the right, which fixed the floating segments of the 2nd, 3rd, and 5th ribs, and on the left, one spoke, which fixed 3 ribs. In addition, to fix the rib-sternum floating segment along the 7th rib above the sternum, a spoke was made from the right to left stable segments of the ribs. Due to the fact that the patient was scheduled for an extended mechanical ventilation, to ensure a more reliable fixation of the fragments, a traction was applied over the sternum with a load of 4.5 kg and a tracheostomy was performed. From 11 to 13.06.03, the patient was in medical sedation on mechanical ventilation in IPPV mode with FiO ₂ - 0.5, from 13 to 23.06 mechanical ventilation was in BiPAP assist mode, from 23.06 transferred to spontaneous breathing with O ₂ insufflation.

Given the stabilization of the patient’s condition, resolution of acute respiratory failure, positive radiological dynamics, restoration of the chest frame, 06/24/03 traction for the sternum was removed, the tracheostomy tube was removed. 07.07.03 a patient in satisfactory condition was discharged for outpatient monitoring by a surgeon. On July 20, 2003, spokes were removed on an outpatient basis. With R-graphy, the position of the fragments is stable.

The proposed method allows to achieve sufficient stabilization of the costal framework, providing adequate breathing function and to perform minimally invasive elimination of intrapleural complications of the injury.

Claims (3)

1. A method for minimally invasive fixation of ribs in case of multiple and floating fractures by reposition of fragments with ligatures under them, characterized in that by the puncture method outside the zone of injured soft tissues a knitting needle is carried out subfascial over the floating fracture, then pericostal sutures are placed on stable fragments and the floating segment , fixing them to the spoke with a simultaneous reposition of fragments, and the operation is performed with thoracoscopy. 2. The method according to claim 1, characterized in that carry Kirschner needle. 3. The method according to claims 1 and 2, characterized in that the pericostal sutures are applied using a stylet needle.

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