RU2285474C2 - Method for treating brachial fractures - Google Patents

Abstract

FIELD: medicine, traumatology, orthopedics.

SUBSTANCE: the present innovation deals with treating motor system traumas due to modifying the method for perosseous brachial osteosynthesis. Through proximal and distal fragments one should apply per 4 needles ⌀ 1.5 mm, all in similar direction and in similar plane: from the bottom - upwards, from the outside - inside, at some distance against the sites of the main vascular-nervous brachial formations. Two needles applied through each fragment should be cut right at skin border in area of m.triceps brachii. Two other needles should be cut right at skin border in area of m.biceps brachii. Then every needle should be fixed right above the skin, its loose part should be bent at the angle of 90°. Needles should be fixed upon 1-2 thread rods, needles should be applied at some distance against radial and ulnar nerves, brachial artery and median nerve. The innovation suggested provides improved quality of fixation and prevents articular rigidity.

EFFECT: higher efficiency of therapy.

1 cl, 8 dwg, 1 ex

Description

The invention relates to medicine, in particular traumatology and orthopedics, and can be used in the treatment of various fractures of the humerus.

Fractures of the humerus are common enough. They make up from 4 to 20.8% of all fractures of limb bones (Kaplan A.V. et al. 1979, Ilizarov G.A. et al. 1991, Shevtsov V.I. et al. 1995). Despite the many modern methods of treatment used, the number of complications and unsatisfactory results remains high. So, unsatisfactory results in the treatment of fractures of the humerus by conservative methods range from 7.5 to 50%, and when applying surgical treatment from 1.6 to 57.1% (Shevtsov V.I. et al. 1995, Linnik S.A. et al. 2002, Biasbett J. et all. 1990). Complications in the form of damage to the radial and ulnar nerves, the formation of pseudoarthrosis and nonunion fractures, delayed consolidation, joint contractures, and the development of purulent complications range from 0.7 to 30.2% (Ilizarov G.A. et al. 1991, Shevtsov V.I. . et al. 1995, Linnik S.A. et al. 2002, Baskakov A.A. et al. 2002).

A known method for the treatment of fractures of the humerus is transosseous (extra focal) osteosynthesis (Shevtsov V.I., Shved S.I., Sysenko Yu.M. Treatment of patients with fractures of the humerus and their consequences by transosseous osteosynthesis. - Kurgan, RRC "WTO" , 1995. - P.223). The method is less traumatic, gives good anatomical and functional results. However, the devices used for transosseous osteosynthesis of the humerus (Ilizarova, Tkachenko, Volkov-Oganesyan, Kalnberz, Gudushauri, etc.) are rather bulky, difficult to care for, and often poorly tolerated by patients. Their arrangement of 3-4 ring supports is heavy and not functional enough. Carrying mutually intersecting spokes in the ring supports of these devices at an angle of 90 °, as required by the rules of external fixation, in most cases is impossible due to the peculiarities of the topographic anatomy of the neurovascular bundles of the shoulder and the possibility of damage. Holding spokes from different angles leads to a weakening of the rigidity of the apparatus. Finding the proximal and distal annular supports in close proximity to the shoulder and elbow joints sharply limits the possibility of movements in them, which leads to complications such as stiffness and contractures. Partial or complete replacement of spokes with rod clamps (spoke-rod or rod devices) give a positive effect. The devices are becoming more functional and manageable, but more bulky. In addition, the fixation of fragments by the rods is much more traumatic than by the spokes, and leads to an additional weakening of the strength of the bone itself (the diameter of the spokes is 1-1.5 mm, the diameter of the rod is 5-7 mm). A feature of the treatment of fractures of the humerus by the method of extra focal osteosynthesis is that the reposition and fixation of fragments occurs almost "blindly", without visual monitoring of their quality. The consequence of this is that often during the operation it is not possible to achieve a complete reposition and high-quality fixation of the fragments, and after the operation it is necessary to additionally repair the fragments with the help of parts and units of the apparatus, carrying out additional knitting needles, etc. The latter does not affect the treatment outcomes in the best way. and on the moral and psychological state of the patient.

The aim of the invention is to improve the method of transosseous (extra focal) osteosynthesis in the treatment of fractures of the humerus by improving the quality of reposition and fixation of fragments, facilitating the external fixation apparatus, improving metal construction, eliminating complications of osteosynthesis (damage to the neurovascular bundles) and complications of the postoperative nature (stiffness and joint contractures )

Operation technique.

The patient was placed on the operating table in a supine position. A needle was drawn through the ulnar process and skeletal traction was established. The shoulder was given a 90 ° lead position, an external rotation of 20 °, and an anterior deviation of 20 °. Traction eliminated the displacement along the length.

From a small surgical approach, depending on the location of the bone damage (up to 4-5 cm long), the fracture site was exposed. Under visual and palpation control, an open reposition of fragments and fixation with tools was performed. Then through the proximal and distal fragments 4 spokes ⌀ 1.5 mm were drawn, all in the same direction and plane: from bottom to top and from outside to inside. Mutual crossover of the spokes at an angle close to 90 ° (as occurs in conventional external fixation devices), was not performed. Thus, all the spokes were held at a considerable distance from the places of passage of the main vascular-neural formations of the shoulder (radial and ulnar nerves, brachial artery and median nerve), which excluded their iatrogenic damage. Each 1 and 3 knitting needles drawn through each fragment bite directly at the skin border in the lower part of the shoulder (in the region of m. Triceps brachii), and each 2 and 4 knitting needles bent directly at the skin border in the region of the upper shoulder (in the m biceps brachii). Knitting needles from the area of "bends" from the skin were knocked into the depths of soft tissues. Thus, each fragment recorded 4 spokes, 2 in the upper part of the shoulder and 2 in the lower part of the shoulder. Then, with the help of sequestral clamps, each spoke was fixed directly above the skin, and its free part was bent at an angle of 90 °. Using ring special fixators, the spokes were fixed on 1-2 threaded rods. Fixation of fragments with tools stopped. The wound was sutured in layers tightly.

Thus, the advantages of the operation according to the specified method are:

1. The combination of visual control over the quality of reposition of fragments with external fixation of the fracture.

2. Minimum invasiveness of the operation (surgical access within 4-5 cm)

3. Holding spokes in functionally inactive zones (outside large muscle-fascial groups) and at a considerable distance from the main neurovascular bundles.

4. Reducing the mass of the apparatus due to the lack of ring supports and reducing the number of threaded rods to 1-2 (in the traditional layout of the Ilizarov apparatus 9 threaded rods).

5. Prevention of the development of stiffness and contracture of the joints by finding the spokes and threaded rods at a considerable distance from the shoulder and elbow joints.

6. Increasing the rigidity of the structure due to the angular bending of the spokes.

7. The possibility of early restoration of limb function due to the minimum layout of the apparatus and the lack of metal structures in the joints.

Under our supervision, there were 39 patients with fractures of the humerus who were treated using the method of extra focal osteosynthesis. Patients were divided into 2 groups depending on the method of treatment. In the first (n = 24), a closed reposition of fragments was performed with the application of the apparatus of G.A. Ilizarov. In the second group (n = 15), patients were treated according to our proposed method. The duration of fixation of fragments by the apparatus, the duration of inpatient and general treatment, restoration of the deficit of range of motion in the shoulder and elbow joints in the postoperative period, the presence or absence of complications were compared.

When assessing the duration of fixation of fractures by the apparatus (Figure 1), it was found that in group 1 it was 64.3 ± 9.7 days, and in group 2 it was 61.2 ± 9.4 days. Thus, the duration of fixation in group 2 was 1.05 times shorter than in group 1, which is statistically unreliable and therefore not comparable. The duration of inpatient treatment (Figure 2) in group 1 was 17.6 ± 3.9 days, and in group 2 12.9 ± 2.1 days. Thus, the duration of inpatient treatment in group 2 was 1.4 times less than in group 1. The duration of general treatment in the groups was also less in group 2 (52.7 ± 7.3 days) than in group 1 (61.8 ± 8.4 days) 1.2 times (Fig. 3).

Comparing the dynamics of restoration of the deficit of range of motion in the shoulder and elbow joints in the postoperative period, it was found that faster joint function was restored in group 2.

Assessment of the deficit of range of motion in the shoulder joint after fractures of the humerus was carried out by an average indicator, the volume of flexion, extension and abduction in the joint, as a percentage of normal values (Figure 4).

Throughout the entire observation period after surgery, the deficit of range of motion in group 1 was greater than in group 2, an average of 1.3-1.5 times, and by 60 days it increased to 2.3. By 90 days in the 2nd group there was no deficit of range of movements at all, whereas in the 1st group it was within 9.8% of the norm.

Assessment of the deficit of range of motion in the elbow joint after fractures of the humerus was carried out according to the average indicator, the volume of flexion, extension, pronation and supination in the joint, as a percentage of normal values (figure 5).

Throughout the entire period of observation after surgery, the deficit of range of motion in group 1 was greater than in group 2, an average of 1.2-1.4 times. However, by 60 days in the 2nd group there was no deficit of range of movements at all, while in the 1st group it was within 21% of the norm, and by 90 days it was 15% of the norm.

In group 1, in 4 patients in the postoperative period, radial neuritis was noted, which accounted for 16.7% of the total number of patients in the group, stiffness in the elbow joint in 11 patients (45.8%), and in the shoulder joint in 2 patients (8.3%). In group 2, stiffness in the elbow joint was observed only in 1 patient, which amounted to 6.7% of the total number of patients in this group.

Clinical example. Patient K., IS No. 2932 from 06/18/2000, Diagnosis: Closed fracture of the right humerus in the middle third with the displacement of fragments (Figure 6). The operation was performed: open reposition of fragments, extra focal transosseous osteosynthesis according to the method described above (Fig.7). The postoperative period was uneventful. Sutures were removed on day 8. The duration of inpatient treatment is 10 days. By the time of discharge from the hospital, the range of motion in the shoulder and elbow joints was restored by 75-80% (Fig. 8). The duration of fixation of fragments by the apparatus was 65 days.

Thus, comparing the results of treatment of patients with fractures of the humerus using traditional treatment (closed reposition of fragments + extra-focal osteosynthesis by G.A. Ilizarov apparatus) and using our proposed method, it was found that by combining visual quality control of reposition and fixation of fragments with external fixation of the fracture, minimal invasiveness of the operation, spokes in functionally inactive zones and at a considerable distance from the main neurovascular bundles, weight reduction apparatus due to the lack of ring supports and reducing the number of threaded rods to 1-2, finding the spokes and threaded rods at a considerable distance from the shoulder and elbow joints, increasing the rigidity of the structure due to the angular bending of the spokes and early restoration of limb function, a reduction in the time of inpatient and general treatment 1.2-1.4 times, a decrease in the function deficit of the shoulder and elbow joints by 1.2-1.5 times. Moreover, we achieved an almost complete absence of complications in the postoperative period. The duration of the operation when applying our method was reduced by an average of 15-20 minutes.

Claims (2)

1. A method for the treatment of fractures of the humerus by transosseous osteosynthesis, including exposure of the fracture site, open reposition of the fragments and fixing them with instruments under visual and palpation control, characterized in that 4 spokes ⌀ 1.5 mm are carried out through the proximal and distal fragments, all one direction and plane: from bottom to top, from outside to inside, at a distance from the places of passage of the main neurovascular formations of the shoulder, after which two spokes drawn through each fragment, bite directly at the border to blades in the m.triceps brachii region, two other knitting needles bite directly near the skin border in the m.biceps brachii region, then each knitting needle is fixed directly above the skin, the free part of the knitting needle is bent at an angle of 90 °, the knitting needles are fixed on 1-2 threaded rods. 2. The method according to claim 1, characterized in that all the spokes are carried out at a distance from the radial and ulnar nerves, brachial artery, median nerve.

Images