RU2285486C2 - Method for treating fractures of antebrachial bones - Google Patents

Abstract

FIELD: medicine, traumatology, orthopedics.

SUBSTANCE: one should apply needles ⌀ 1.5 mm through proximal and distal fragments of radius and elbow bone, all being in one direction and in one plane: from the bottom - upwards from volar surface towards rear one, cut every other needle in area of antebrachial volar surface, cut the rest needles in area of rear antebrachial surface, fix needles upon 1-2 thread rods. The innovation enables to decrease the risk in affecting vascular-nervous bundles and developing contractures.

EFFECT: higher efficiency of therapy.

1 cl, 8 dwg, 1 ex

Description

The invention relates to medicine and can be used in the treatment of injuries of the musculoskeletal system by improving the method of transosseous (extrafocal) osteosynthesis in fractures of the forearm bones.

Fractures of the forearm bones are one of the most frequent localizations of injuries to the bones of the limbs. They make up from 7.1 to 41.4% of all bone fractures of limbs (Belyakov A.A., 1978 et al., Ilizarov G.A. et al., 1987, Shved S.I. et al., 1997) . Among them, from 10 to 37% are fractures of the distal metaepiphysis of the forearm bones (Vorontsov P.M. et al., 1997, Golubev I.O. et al., 1999, Afaunov A.I. et al., 2001), and in in old age, the proportion of such fractures increases to 50-58% (Al-Shorman M. et al., 2004). Despite such a frequent pathology, the quality of treatment for patients with fractures of the forearm leaves much to be desired. So, in the treatment of fractures of the forearm bones with conservative methods, unsatisfactory results occur from 13 to 60% and from 10.3 to 70% during surgical treatment, and disability from 0.7 to 16.6% during conservative treatment and from 6 to 41, 4% during surgical treatment (Ilizarov G.A. et al., 1987, Tailashev M.M. et al., 1995, Shved S.I. et al., 1997, Goryachev A.N. et al., 2000, Volykov P.G. et al., 2002, Solgard S. et all., 1989, Kwasny O. et all., 1990). Contractures, arthrosis in the elbow joint develop in 10.7-63.2% after fractures of the ulnar process (Sysenko Yu.M. et al., 2002, Kopysova V.A. et al., 2002), arthrosis and limitation of hand function are diagnosed in 45.4% of victims of fractures of the distal metaepiphysis of the bones of the forearm (Al-Shorman M. et al., 2004). Secondary displacement of fragments during comminuted fractures of the distal metaepiphysis of the radius occurs in 23-46% of cases (Baimagambetov S.A. et al., 1996), and neurodystrophic Sudeck-Turner syndrome with this pathology is diagnosed in 6-31% of patients (Ternova N. K. et al., 1989). Improperly fused fractures and false joints after closed diaphyseal fractures of the forearm bones develop in 5–9% of patients, and the period of incapacity for work reaches 5.3 months. (Belyakov A.A. et al., 1978). Thus, the optimization of the quality of treatment for patients with fractures of the forearm bones is an urgent task of traumatology and orthopedics.

A known method of treating fractures of the forearm bones is transosseous (extra focal) osteosynthesis (Shved S.I., Shevtsov V.I., Sysenko Yu.M. Treatment of patients with fractures of the forearm bones using transosseous osteosynthesis // Methodical recommendations. RRC "WTO". - Kurgan, 1997 .-- P.295). The method is less traumatic, gives good anatomical and functional results. However, the Ilizarov apparatus used for transosseous osteosynthesis of the bones of the forearm is rather cumbersome, difficult to assemble and subsequently care for, and is often poorly tolerated by patients. Its arrangement of 3-4 ring supports is heavy and not functional enough. Mutually intersecting spokes in the annular supports of these devices at an angle of 90 °, as required by the rules of external fixation, in most cases is impossible because of the peculiarities of the topographic anatomy of the neurovascular bundles of the forearm 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 elbow and wrist joints severely limits the possibility of movement 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 even more cumbersome. In addition, the fixation of fragments by the rods is much more traumatic than by the knitting needles and leads to an additional weakening of the strength of the bone itself (the diameter of the spoke is 1-1.5 mm, the diameter of the rod is 5-7 mm). A feature of the treatment of forearm bone fractures by the method of extra focal osteosynthesis is that the reposition and fixation of fragments occurs almost "blindly", without visual monitoring of their quality. It is known that the displacement of fragments of the forearm bones, in particular during fractures of the radius and ulna in the middle third, occurs in four directions: namely, along the length (due to muscle contraction), in width (due to the features of the injury mechanism), at an angle open to the palmar side (due to traction of more powerful flexors of the forearm and hand) and rotational (due to the reduction of m. pronator teres). The consequence of this is that often during a closed reposition operation it is not possible to achieve 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 by means of additional knitting needles, etc. The latter is not reflected in the best way as outcomes of treatment, 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 forearm bones 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 postoperative complications (stiffness and joint contractures )

Surgery technique for diaphyseal fractures of the forearm bones

The patient is placed on the operating table in a supine position. The shoulder is taken to an angle of 90 °. The forearm is laid on a side table.

From a small surgical approach, depending on the location of the bone damage (up to 3-4 cm long), the site of the fracture of the radius was exposed. Under visual and palpation control, an open reposition of the fragments and fixation by their instruments were performed. Then, through the proximal and distal fragments of the radius and ulna, 4 needles ⌀ 1.5 mm were drawn, all in the same direction and plane: from bottom to top (from the palmar surface to the back) at an angle of 45 °. 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 carried out on the outside of the main muscle-tendon cases and neurovascular bundles (radial and ulnar nerves and arteries), which excluded their iatrogenic damage. Each 1 and 3 knitting needles drawn through each fragment bite directly at the skin border in the area of the palmar surface of the forearm, and each 2 and 4 knitting needles bite directly at the skin border in the region of the dorsal surface of the forearm. 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 from the palmar surface and 2 from the back of the forearm. 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.

Surgery technique for fractures of the radius in the distal metaepiphysis

The patient is placed on the operating table in a supine position. The shoulder is taken to an angle of 90 °. The forearm is laid on a side table.

Make a closed manual reposition of the fracture. R-control in the operating room. With satisfactory standing of the fragments proceed to external transosseous fixation of the fracture. In case of unsatisfactory standing of the fragments, the presence of unrepaired displacements, the site of the radius fracture was exposed from a small surgical approach in the projection of the fracture (up to 3 cm long). Under visual and palpation control, an open reposition of the fragments and fixation by their instruments were performed. Then through the distal fragment 2 spokes were carried out, and through the proximal fragment 3 spokes ⌀ 1.5 mm, all in the same direction and plane: from bottom to top (from the palmar surface to the back) at an angle of 45 °. The needles drawn through each fragment bite through one directly at the skin border in the area of the palmar surface of the forearm, and the remaining needles bite directly at the skin border in the area of the dorsal surface of the forearm. Knitting needles from the area of "bends" from the skin were knocked into the depths of soft tissues. 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 threaded rod. Fixation of fragments with tools stopped. The wound was sutured in layers tightly.

Thus, the advantages of the operation according to the specified technique is:

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 3-4 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 contractures of the joints by finding the spokes and threaded rods at a considerable distance from the elbow and wrist joint.

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.

We observed 81 patients with fractures of the forearm bones, which 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 = 39), a closed reposition of fragments was performed with the application of the apparatus of G.A. Ilizarov. In the second group (n = 42), 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 elbow and wrist 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 54.3 ± 6.7 days, and in group 2 it was 52.8 ± 6.5 days. Thus, the duration of fixation in group 2 was 1.03 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 13.6 ± 3.7 days, and in group 2 - 10.2 ± 2.5 days. Thus, the duration of inpatient treatment in group 2 was 1.3 times less than in group 1. The duration of general treatment in the groups was also less in group 2 (61.5 ± 7.9 days) than in group 1 (74.3 ± 8.9 days) 1.2 times (Figure 3).

Comparing the dynamics of recovery of the deficit of range of motion in the elbow and wrist 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 elbow joint after fractures of the forearm bones was carried out according to the average indicator, the volume of flexion and extension in the joint, as a percentage of normal values (Figure 4).

On the 15th day after the operation, the deficit of the range of motion in the 1st group was 1.2 times greater than in the 2nd group, and by 1.4 times on the 30th day. It is characteristic that by 60 days in the 2nd group there was no deficit in the range of movements in the elbow joint, while in the 1st group it amounted to 22.7% of the norm on the 60th day and 17.7% of the norm on the 90th day.

Assessment of the deficit of range of motion in the wrist joint after fractures of the forearm bones was carried out by an average indicator, by the amount of flexion, extension in the joint, as well as the radial and ulnar abduction as a percentage of normal values (Figure 5).

From the analysis of the graph it follows that on the 15th day after the operation, the deficit of the range of movements in the wrist joint was 69.5% in the 1st group, then 57.7% in the 2nd group, i.e. was 1.2 times larger. By day 30, the deficit of range of motion in group 1 was 37.5% of the norm, while in group 2 it was 19.9% of the norm, i.e. 1.8 times less. From day 60, there was no deficit of range of motion in group 2 at all, whereas in group 1 by day 60 it amounted to 14.3% of the norm, and by day 90. respectively 7.9%.

In group 1, stiffness in the elbow joint was noted in 7 patients (17.9%), and in the wrist joint in 1 patient (2.6%). In group 2, stiffness in the elbow joint was observed in 2 patients, which amounted to 4.8% of the total number of patients in this group.

Clinical example

 Patient D., Information Security No. 1470 of March 25, 2002. Diagnosis: Closed fracture of the left radial and ulnar bones in the middle third with the displacement of fragments (Figure 6). The operation was performed: open reduction of fragments of the radius and ulna, extrafocal transosseous osteosynthesis according to the method described above (Fig.7). The postoperative period was uneventful. Sutures were removed on day 9. The duration of inpatient treatment is 11 days. By the time of discharge from the hospital, the range of motion in the shoulder and elbow joints was restored by 80-85% (Fig. 8). The duration of fixation of fragments by the apparatus was 50 days.

Thus, comparing the results of treatment of patients with fractures of the forearm bones using traditional treatment (closed reposition of fragments + extrafocal 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, holding spokes in functionally inactive zones and at a considerable distance from the main neurovascular bundles, reducing mass The apparatus due to the absence of ring supports and the reduction in 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, reduces the terms of stationary and general treatment by 1.2-1.3 times, reducing the deficit of the function of the elbow and wrist joints by 1.2-1.8 times. At the same time, we sought to reduce the number of complications in the postoperative period by 4.3 times. The duration of the operation when applying our method was reduced by an average of 15 minutes

Claims (2)

1. A method of treating forearm bone fractures, including access to the fracture site, open reposition under visual and palpation control, fixation of fragments with tools, characterized in that spokes что 1.5 mm are passed through the proximal and distal fragments of the radius and ulna, all in one direction and plane: from bottom to top from the palmar surface to the back, the needles bite through one in the area of the palmar surface of the forearm, the remaining needles bite in the area of the back surface of the forearm, the needles are fixed for 1-2 threads rods. 2. The method according to claim 1, characterized in that the needles bite directly at the border of the skin.

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