RU2282410C2 - Method for treating the defect of elbow nerve in case of its open lesion in area of elbow joint - Google Patents

Abstract

FIELD: medicine, traumatology.

SUBSTANCE: the present innovation deals with treating traumatic defects of elbow nerve at the level of elbow joint. It is necessary to reconstruct the integrity of the nerve due to preliminary length margin due to dosed traction of its part at daily tempo ranged 0.5-1.0 mm. Then one should mobilize, descend and suture according to "end-to-end" type. The creating of nerve's length margin should be carried out within healthy tissues at the border of the middle and inferior third of a shoulder, moreover, traction impact should be suggested, as a whole, onto corresponding part of elbow vasculo-nervous bundle without dissecting median fascial septum. One should start traction impact at any stage of wound process to fulfill it in anterior-median direction. Prolonged part of the nerve should be fixed for about 10-15 d. The innovation enables to provide substitution of the defect and anatomo-functional reconstruction of elbow nerve in case of open lesion of elbow joint.

EFFECT: higher efficiency of therapy.

1 ex

Description

The invention relates to medicine, in particular to traumatology, and can be used in the treatment of traumatic defects of the ulnar nerve at the level of the elbow joint.

A known method of treating a nerve defect at the level of the elbow joint [1], providing for its subcutaneous transposition in the anterior bed. The method is traumatic, coupled with the need to cross a large number of muscle branches of the nerve extending from it at the level of the elbow joint, or perform an osteotomy of the internal condyle of the humerus - with transposition in a short way. In addition, the method is applicable only after complete healing of the wounds and creates the risk of ischemic fibrosis of the mobilized sections of the nerve.

A known method of treating the consequences of injuries of nerve trunks of a limb [2], including restoring the integrity of the nerve by first creating a stock of length due to the dosed traction of its section in the transverse direction, mobilizing, releasing and then stitching "end to end".

However, this method is also used after complete healing of the tissues and does not contain special techniques that take into account the anatomical and functional features of the ulnar nerve.

The objective of the invention is to develop a method of treating a defect in the ulnar nerve, ensuring its anatomical and functional recovery with open damage in the elbow joint.

This problem is solved by the fact that in the method of treating an ulnar nerve defect with open damage to the elbow joint, including restoring nerve integrity by first creating a length margin due to the dosed traction of its section in the transverse direction with a daily rate of from 0.5 to 1.0 mm, mobilization, reduction and subsequent stitching "end to end", the creation of a reserve of the length of the nerve is carried out within healthy tissues on the border of the middle and lower third of the shoulder, and the traction effect is spruce on the corresponding section of the ulnar neurovascular bundle without dissecting the medial fascial septum, start it at any stage of the wound process and perform it in the anteromedial direction, after which the elongated nerve section is stably fixed for 10-15 days.

It is provided that, starting from the 7-10th day of traction, its rate is set based on the data of cutaneous blood flow in the elongation zone and a similar section of the contralateral limb, and in the presence of negative asymmetry, the rate should not exceed 0.5 mm per day.

The invention is illustrated by a description and an example of clinical use.

The method is as follows.

In the presence of open, including infected, damage to the elbow joint at any stage of the wound process, diagnostic data indicating an anatomical interruption or intra-trunk injury to the ulnar nerve with a poor prognosis of recovery of function are the basis for using the proposed method. When it is implemented, the elbow joint is initially immobilized with, if necessary, reposition of bone fragments using an external fixation apparatus. After that, within healthy tissues, on the border of the lower and upper third of the shoulder, the skin, subcutaneous tissue are dissected from the side of the long head of the triceps muscle and without cutting the medial fascial septum, the elbow vascular bundle (ulnar nerve and collateral vessels accompanying it) is economically mobilized. Under the mobilized section of the neurovascular bundle, the supporting element of the traction device is brought. The spokes of the support element, removed from the wound through punctures of the fascial septum, subcutaneous tissue and skin, are connected to the nodes of the traction system mounted on the support of the apparatus. Having stabilized the position of the support element and the traction system, the wound is sutured.

From 3-7 days after the operation, metered traction of a fixed portion of the neurovascular bundle in the anteromedial direction is performed with a daily rate of 1 mm in at least 4 doses (0.25 mm at a time). Starting from the second week of lengthening, flowmetry of the skin blood flow is performed in the zone of maximum stretching of the skin and in a similar area of the contralateral limb. In the presence of negative blood flow asymmetry, the daily rate is reduced to 0.75 mm or even to 0.5 mm. When calculating the required magnitude of elongation, it should be borne in mind that nerve tension during transverse traction occurs simultaneously at two levels. With an average daily rate of 0.75 mm and good blood supply, nerve extension will be approximately 1 cm per week.

After creating the necessary margin of nerve length, traction is stopped and the elongated section of the neurovascular bundle is stably fixed (held in its attached position) for 10-15 days. This prevents the elastic contraction of the nerve, which is possible after the termination of traction, since during the elongation of the tissue they do not have time to build up their volume.

At the end of the fixation period, the nerve is accessed in the region of the supporting element, which, after dissection of the connective tissue capsule formed around it, is removed. Following this, the elongated nerve is mobilized and reduced, maximally sparing the accompanying vessels and branches extending from the nerve to the muscles of the forearm. Find the end of the nerve distal to the damage zone. The scarred sections of the nerve are removed, its ends are brought together in the natural bed or after transposition (depending on the size of the defect and the nature of the damage). The joint is fixed in the mid-physiological position. With the help of microsurgical technique, the suture of the nerve is performed end to end. The wound is sutured in layers. In the postoperative period, the joint is developed using an external fixation device.

The practical use of the method is illustrated by the following clinical observation.

Patient K., born in 1963, as a result of careless handling of a gun, received a gunshot wound to the right elbow joint with damage to the ulnar nerve. On the day of the injury, a PHO of the wounds was performed, osteosynthesis by the Ilizarov apparatus of the upper limb. After 1.5 months (in the presence of an infected wound in the region of the medial condyle of the humerus), a traction system was installed on the intact section of the proximal ulnar stump at the middle third of the shoulder. After 3 days, nerve traction was started at a rate of 0.75 mm per day for 3 doses, which lasted for 45 days. The fixation period was 2 weeks. An audit was made of the n.ulnaris damage zone, the defect of which was 4 cm. By mobilizing the proximal stump and lowering the elongated nerve section in its own bed (without transposition), it was possible to suture the nerve end to end without tension (elbow joint in the middle physiological position) . After 10 days, the dosed development of movements in the joint was started using the Ilizarov apparatus. The patient was examined 2.5 months after surgery on the ulnar nerve, documented positive neurological dynamics (reduction of atrophy of the small muscles of the hand, the appearance of flexion movements in the metacarpophalangeal joints, a positive test of scratching with the little finger, the appearance of deep and tactile sensitivity in 4-5 fingers).

Using the method provides compensation for the defect and anatomical and functional restoration of the ulnar nerve with open damage to the elbow joint. The method is less traumatic, optimizes the reparative process, including in the treatment of infected and gunshot wounds. This effect is achieved by stimulating the macrophage reaction and enhancing the barrier properties of tissues, maintaining dilated remodeling of the great vessels and neoplasm of small vessels in the traction zone and in the area of damage, creating a reserve of nerve length within healthy tissues to complete the suture end to end without tension during its segmental defect, in the restructuring of the intraneural blood supply system, contributing to a more rapid restoration of the vascularization of the mobilized sections of the nerve.

Information sources

1. Dolnitsky OV, Dolnitsky Yu.O. Atlas of microsurgical nerve surgery. A practical guide. Kiev: Vyscha school, 1991 .-- 182 S.

2. RF patent 2080826, publ. 06/10/97, bull. 16.

Claims (1)

A method of treating an ulnar nerve defect with open damage to the elbow joint, including restoring the integrity of the nerve by first creating a length margin due to the dosed traction of its area with a daily rate of 0.5 to 1.0 mm, mobilization, releasing and subsequent stitching "end to the end ", characterized in that the creation of a reserve of the length of the nerve is carried out within healthy tissues on the border of the middle and lower third of the shoulder, and the traction effect is generally provided on the corresponding section of the elbow of the neurovascular bundle without dissecting the medial fascial septum, start it at any stage of the wound process and perform it in the anteromedial direction, after which the elongated nerve section is stably fixed for 10-15 days.