RU2301032C2 - Surgical method for treating patients for complicated calcaneus fracture - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves detaching tibial nerve and long flexor tendon of the first toe from medial calcaneus wall exostosis. The exostosis is removed its base is filed and rubbed with wax. Released tendon and nerve are placed into anatomically right position.

EFFECT: enhanced effectiveness of treatment.

3 dwg

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used for fractures of the calcaneus complicated by neuritis of the tibial nerve and flexion contracture of the 1st toe.

There are various complications of calcaneus fractures: deforming arthrosis of the subtalar joint (Eretskaya M.F. Treatment of calcaneus fractures // Dis. Doctor of Medical Sciences. - Leningrad. - 1967; Koshkareva Z.V. Treatment of calcaneus fractures and their consequences / / Diss. Candidate of Medical Sciences. - Novosibirsk. - 1979; Cherkess-Zade D.I., Kamenev Yu.F. Foot Surgery // M., Medicine. - 1995. - P.51-68; Fishkin I. B. On the treatment of calcaneus fractures // Orthopedics, traumatology and prosthesis. 1986. No. 3. S. 61-62); painful ankle conflict (Giachino A., Uhthoff H. Current Concepts Review: Intra-Articular Fractures of the Calcaneus // J. Bone Joint Surg. Am. 1993. Vol.75. N.3. P.355-362), sympathetic reflex dystrophy or Sudeck's disease (McGlamry D. Fundamentals of Foot Surgery // Williams & Wilkins, 1993. 689 p.). These phenomena are well studied, and methods for their treatment are described in the literature (Circass-Zade DI, Kamenev Yu.F. Foot Surgery // M., Medicine. - 1995. - P.51-68; Sanders R., Gregory P. Operative treatment of intraarticular fractures of calcaneus // Orthop. Clin. North America. 1995. Vol.26. P.203-214; Sanders R. Fractures and fractures-dislocations of the calcaneus // In "Surgery of the Foot Ankle "St. Louis, Mosby 1999. Vol.2. P.1422-1464).

About the complication accompanied by the irritation of the tibial nerve branches and the appearance of pains on the inside of the calcaneus in this connection, there is only mention and there is no description of this symptom complex and its treatment (Myerson M., Quill G. Late complications of fracture of calcaneus // J Bone Joint Surg. Am. 1993. Vol. 75. N.3. P.331-341).

The objective of the invention is to propose a method that improves the results of the treatment of calcaneus fracture by creating optimal conditions for the regeneration of the tendon of the long flexor of the 1st finger and tibial nerve.

When solving this problem, conditions are created for restoring the conductivity of the tibial nerve and its branches, sliding of the tendon of the long flexor of the 1st finger, thereby achieving a positive therapeutic effect. When solving the problem, there is an economic effect due to the reduction of the period of temporary disability, exit to disability; social effect - improving the quality of life.

The technical result is achieved by restoring the anatomical structure of the calcaneus, which ensures the function of the foot.

The problem is solved due to the fact that the exostosis of the medial wall of the calcaneus is revealed, the tibial nerve fixed to it and the tendon of the long flexor of the first finger are separated, the exostosis is removed, its base is treated with wax, and the released tendon and nerve are laid in the anatomically correct position

The method is as follows. The patient is placed in the “on the back” position. The sick leg is laid on the rollers in the position of the external rotation of 10-15 °, the knee joint is bent to 160-165 °. The surgical field is treated and an incision is made from a point 5 cm cranial to the inner ankle and 2 cm back dorsally. Soft tissues are dissected to the bone, around the inner ankle and 2 cm from its pole, after which the incision is directed to the scaphoid, where it ends. A deltoid ligament is dissected, tendons, nerves, exostosis and anatomical structures fixed to it are localized.

During the audit, exostosis of the medial calcaneus and scars fixed to it by the posterior tibial nerve and tendon of the long flexor of the 1st toe are revealed. The degree of incorporation of bone tissue into the tissue of the nerve and tendon is noted. Alternately stupid and acute way, the nerve and tendon are separated from exostosis, according to indications, tendonysis of the tendon or neurolysis of the posterior tibial nerve is performed. The next step is to remove exostosis, grind the base of the exostosis and wipe it with wax. The vacated tendon and nerve fit into the anatomically correct position. The wound is sutured.

An example of a specific application. Patient B., 25 years old, medical history No. 1572/02, when falling from a height of 2 meters, received a comminuted transarticular fracture of the right calcaneus with displacement of the fragments on July 15, 01. He received skeletal traction treatment for 2 weeks, then by external immobilization with a plaster cast for up to 2 months. Examined on an outpatient basis 05.10.01 with complaints of pain, deformation of the hindfoot, impaired sensation of the sole of the foot, impossibility of extension of the 1st finger (figure 1).

Clinical and radiological examination revealed a fractured heel bone consolidated in a vicious position, extensor contracture of 1 toe of the right foot in a position of vicious fixation of a finger of 10 ° plantar flexion, complete anesthesia of the sole. A bone density of 0.5 × 0.5 cm was palpated deep in the tissues of the medial calcaneus. It was noted that traditional radiography was ineffective for diagnosing the morphological substrate of this damage (Fig. 2), and the patient underwent computed tomography, which revealed morphological pathology substrate: medial propping fragment of the left calcaneus, fracture of the inner wall of the calcaneus on the right without displacement of fragments (figure 3).

After carrying out diagnostic measures and clarifying the diagnosis, the patient was operated on. The patient underwent corrective subtalar arthrodesis according to Carr, internal fixation with screws of type A / O from internal access. Under general anesthesia, a soft tissue incision was performed, exostosis was visualized, the nerve and tendon were separated from it, the medial exostosis of 2 × 3 × 1 cm was removed, tenolysis of the long flexor of the 1st finger and neurolysis of the posterior tibial nerve were performed. The base of the exostosis is polished and waxed. The vacated tendon and nerve are laid in an anatomically correct position. The wound is sutured in layers. Healing by first intention by the 10th day after surgery. After removal of the sutures, the patient was given a circular plaster cast in the mid-physiological position of the foot, up to the knee joint. Starting from the 3rd day after the operation, the patient noted a clear improvement in the sensitivity of the sole of the foot and an increase in the volume of passive and active movements with the 1st finger of the operated foot. Clinical signs of the restoration of the functions lost as a result of the trauma increased, and upon examination 8 months after the operation, restoration of the sensitivity of the sole of the foot and active back flexion of the finger to 13 ° were noted. According to the control radiographs dated 04.24.02, artifactal subtalar bone ankylosis in the correct position, transplant remodeling, minor degenerative changes in the bones and joints of the foot. The result is regarded as good.

Claims (1)

A method for surgical treatment of a complicated calcaneus fracture, characterized in that exostosis of the medial calcaneal wall is revealed, the tibial nerve and the tendon of the long flexor of the first finger are fixed to it, the exostosis is removed, its base is ground and waxed, and the released tendon and nerve are laid anatomically the correct position.

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