RU2311155C1 - Method for treating the fractures of long tubular bones - Google Patents

Abstract

FIELD: medicine, traumatology, cryomedicine.

SUBSTANCE: the present innovation deals with reposition, mobilization of osseous fragments and impact upon the fracture area. Moreover, after edema is over it is necessary to affect with cold: at first, one should treat a skin part in the projection of the area with a cotton tampon impregnated with a cooling agent till light skin whitening. Then comes cryomechanical impact with a porous mobile roller out of titanium nickelide filled with liquid nitrogen along skin surface in projection of the fracture area with reciprocation for the period of about 7-10 min. Moreover, at first, during 3.5-5 min one should perform movements in longitudinal direction, and during the rest period of time - in transverse and oblique directions, and then, by alternating them by turns. The course consists of 6-10 seances carried out either daily or every other day. The innovation enables to create conditions for osteoreparative processes and decrease complications associated with tissue traumatization.

EFFECT: higher efficiency of therapy.

8 dwg, 2 ex, 1 tbl

Description

The invention relates to medicine, cryology, traumatology and can be used to treat fractures of long tubular bones.

Slow bone consolidation in the treatment of fractures of long tubular bones according to different authors occurs in 0.5-33.1% of cases when, after the average time required for fusion, after the formation of sufficient bone callus does not occur. After removing the plaster cast or transosseous fixation device, slight mobility or only soreness at the site of the former fracture in determining mobility is detected. On radiographs there is a weakly expressed bone callus, the formation of which occurs according to the type of “secondary healing” (with the presence of a phase of fibrocartilage of the callus) and for longer periods. With more significant violations of the processes of bone repair, in the absence of signs of consolidation after a double average term of fusion, a false joint is formed. Lack of adequate treatment for longer periods leads to the formation of neo-joint [1, 2].

The optimal conditions for bone tissue fusion are considered to be a good comparison of fragments, their strong fixation and the absence of pathological changes on the part of the most important body systems that could disrupt the creation processes [3, 4]. Proponents of the biological theory of osteosynthesis believe that the creation of sufficient conditions for osteoreparation cannot be achieved without an accurate reposition of bone fragments. However, the studies showed that the most important factor is the preservation of blood supply to the fragments in the fracture zone, and the fixation of the fragments should be carried out with minimal damage to the soft tissues [5]. Despite the disagreement, the unanimous recognition is that the conditions necessary for the fusion of bone fragments are associated with the physiological features of bone tissue, the reproduction of which requires a high level of blood supply. Creating conditions for the fastest normalization of blood flow in the affected segment and revascularization of the affected area is a factor accelerating osteoreparative processes [6]. However, when using known methods, there is not enough active effect on the formation of bone marrow, acceleration of consolidation.

The most common circulatory disorders that inhibit the “primary healing” of bone tissue are noted in diaphyseal fractures. Compensation of circulatory disorders in the fracture zone is slow and usually incomplete due to damage to the main supply arteries of the long tubular bones. In the conditions of late and inferior correction of traumatic blood flow disorders, full-fledged bone fusion cannot be obtained even when stable fixation of fragments is achieved [1, 7]. Known methods, including conducting medical therapy of reopositive multifactorial orientation - anticoagulants, antiplatelet agents, angioprotectors, antispasmodics (clexane, pentoxifyline, solididexide, papaverine, stabizol, etc.) to optimize regional blood flow [1]. Known methods for treating fractures, including conducting courses of treatment with anabolic hormones [2, 3, 4, 5, 6] in order to enhance the reparative processes of bone tissue against the background of continued immobilization of the limb with a plaster cast or in the apparatus of extrafocal percutaneous fixation (AVFF) in combination with a dosed axial load, physiotherapy. In the absence of fusion, against the background of the well-known conservative therapy for fractures of long tubular bones, they resort to surgical methods of treatment: using AUVF or with the extraction of bone fragments directly in the area of delayed consolidation (using plates, bone allo and autoplasty [6, 7]). However, despite the desire to positively influence the consolidation process, during any surgical intervention, additional trauma is applied, worsening the conditions for reparative regeneration of bone tissue.

Closest to the proposed is a method of treating fractures of long tubular bones, which consists in the operational stimulation of bone marrow formation by tunneling along Beck [8]. The operation is performed under local, intraosseous, general or spinal anesthesia in compliance with strict asepsis. Small cuts are made on the skin above and below the site of slow bone consolidation. Through them, a bone fragment (proximal and distal) is drilled with a needle or drill up to 2 mm thick using a drill in different directions, forming channels in them, passing from one fragment to another through the fracture line. Depending on the thickness of the bone from 2-8 points, 10 to 40 channels are drilled. The operation can also be performed by the open method with exposure of the fracture site. In the postoperative period, a plaster cast is applied, and the patient begins to make active movements of the damaged limb. The hemorrhage arising as a result of drilling a bone, opening the bone marrow canal and bone tubules, through which the vessels from one fragment begin to grow into another, the formation of a "bone melee" contributes to the healing of the fracture. Nevertheless, this method of stimulation of osteoreparative processes is invasive, traumatic, is used when bone fragments are well standing and, like many surgical methods for treating slow-growing fractures, can be the cause of postoperative complications: skin necrosis, suppuration, and vascular thrombosis.

A new technical task is to increase the effectiveness of treatment by creating conditions for accelerating osteoreparative processes and reducing complications associated with tissue trauma.

To solve the problem in a method for treating fractures of long tubular bones, including reposition, mobilization of bone fragments and impact on the fracture zone, after the edema subsides, they are exposed to cold, for which they first treat the skin area in the projection of the area with a cotton swab moistened with coolant until the skin is slightly whitened, and then cryomechanical effect on the same zone is carried out by reciprocating movements with a total duration of 7-10 minutes, and in the first 3.5-5 minutes of this period, making movements in the longitudinal m direction and in the rest period of time, performing movement in the transverse direction and at an angle to the longitudinal, and further, alternating them alternately course includes 6-10 sessions performed daily or every other day.

The essence of the method lies in the fact that after reposition of fragments and mobilization of the limb in the AVF (external fixation apparatus), after the edema subsides, not earlier than two weeks later, treatment sessions are started, consisting in exposure to cold, for which the background treatment of the site is carried out first skin in the projection of the fracture zone with a cotton swab moistened with a coolant - liquid nitrogen, until the skin is slightly whitened, then cryomechanical effects are performed with reciprocating movements, for example, using porous x movable rollers of titanium nickelide [9] filled with liquid nitrogen, pressing the roller with moderate force to the skin surface for 7-10 minutes, and at first during the first 3.5-5 minutes they move in the longitudinal direction, and for the rest of the time make movements in the transverse direction and at an angle to the longitudinal, and alternating directions of movement, alternately, the course includes 6-10 sessions, daily or every other day.

With the development of a new direction — the advent of cryosurgical methods of treatment — it became possible to more effectively influence the regenerative processes of various tissues [9, 10]. The clinical tissue effects of cryotherapy are described by many authors: improving microcirculation, lymphatic drainage effect, improving trophism of muscle, connective, bone and cartilage tissues, stimulating regenerative mechanisms, increasing the protective functions of the body due to the formation of local and general immune responses in response to cryotherapy. Blocking nociceptive conduction during a cryosession leads to an increase in the pain threshold, causes muscle relaxation (decreased basal muscle tone), thereby exerting an effective effect on muscle contractures [11]. Considering the positive aspects of cryosurgical treatment described above and the biomechanical factors in the formation of bone callus, the applicants considered it appropriate to apply cryotherapy for regenerative therapy of slow-growing fractures of long tubular bones.

Background treatment of the skin area in the projection of the fracture zone with a cotton swab dipped in liquid nitrogen to lightly whiten the skin is necessary to stimulate the formation of bone callus, cryomechanical action with reciprocating movements in the longitudinal direction, corresponding to the direction of large vessels, helps to create conditions for increased blood flow in them and further by means of reciprocating movements in the transverse and at an angle to the longitudinal direction, it contributes to the alternate filling of those neglected as a result post-traumatic edema and hemorrhage of small vessels, improved microcirculation. The duration of the total exposure session of less than 7 minutes is insufficient for the appearance of a vascular reaction in the form of moderate reddening of the skin, and an exposure of more than 10 minutes can cause excessive thermal tissue, which can lead to the appearance of stasis in the vessels, thromboembolism. Moreover, during the first 3.5-5 minutes it is necessary to carry out cryomechanical effects in the longitudinal direction, which helps to increase blood supply in the projection of the fracture and create favorable conditions for an increased influx of nutrients and collagen conversion, and promotes the formation of bone marrow. The course includes 6-10 sessions conducted daily or every other day, depending on individual tolerance.

Example 1. B-naya Sh., 15 years. Closed fracture of both bones of the left tibia. Within 1 month, the treatment was carried out with fixation by the Ilizarov apparatus. Pain was noted at the fracture site during palpation, discomfort during walking and movements (Fig. 1). The treatment was carried out according to the proposed method.

Figure 2 and 3 - treatment with a cotton swab soaked in liquid nitrogen of the site in the projection of the fracture, then the cryomechanical effect of the porous roller of titanium nickelide for 10 minutes. Of these, the first 5 minutes of movements in the longitudinal direction. The rest of the time - alternating in the transverse and oblique directions. The procedure was accompanied by a slight tingling, tingling. Upon cessation of cryotherapy, a slight reddening of the skin appeared due to the excitation of capillary blood flow. A sensation of warmth was noted in the entire segment of the limb. The reaction lasted for 2-3 hours. Repeating sessions every other day. The total number is 10 sessions.

Figure 4. After 10 days, the activation process of repair is determined on the roentgenogram - the appearance of bone marrow.

Figure 5. After 3 weeks of treatment. Bone callus is expressed. There are no unpleasant sensations in the region of the left lower leg. The patient actively uses the lower limb. After 10 days - the removal of the Ilizarov apparatus.

Example 2. Girl Nastya, 10 years old, comminuted fracture of both bones of the lower third of the leg in a car accident, treatment in a plaster cast for a month was assessed as ineffective - a wide line of fracture, no signs of bone marrow formation. The treatment was prescribed according to the proposed method - treatment of the skin area in the projection of the fracture, for which a 5 × 8 cm window was made in a plaster cast, then for the first 3.5 minutes a roll of porous titanium nickelide filled with liquid nitrogen in the longitudinal direction, in the remaining 3, 5 minutes - in the transverse and oblique directions, alternately, a total of 6 sessions conducted every day. After 2 weeks, the disappearance of a wide fracture line was noted with the replacement of its formed bone marrow. After another 2 weeks, complete consolidation was noted followed by removal of the plaster cast.

The proposed method for the treatment of fractures of long tubular bones was applied in 12 patients who received treatment in plaster bandages or in the AFF. Not all patients achieved a good comparison of bone fragments (multi-fragmented fractures), some patients had significant soft tissue damage - this determined the varying severity of regional blood flow disturbance in the damaged segments. The periods of fixation of bone fragments exceeded the average terms of fusion of diaphyseal fractures. Despite the application of various well-known methods of stimulation of osteoreparative processes (medication, electrical stimulation, Beck tunneling), bone marrow was not traced or poorly traced in control radiographs. This indicated that the processes of osteoreparative fractures in these patients were slow. All patients were treated according to the proposed method, at the first stage, background cryoprocessing of the skin of the damaged segment was carried out with a cotton swab moistened with liquid nitrogen until lightly whitened. Then, within 7-10 minutes, a cryomechanical effect was exerted by a porous movable titanium nickelide roller filled with liquid nitrogen with moderate pressure on the tissue in the directions: first, in the longitudinal direction for the first 3.5-5 minutes, then the rest of the time segment and at an angle to the longitudinal direction, in the projection of the fracture zone, then - alternately alternating directions. In this case, the temperature in the area of influence was measured. The temperature reaction on the skin surface before the start of the procedure corresponded to + 36.4-36.6 °, at the end of cryotherapy - + 20-25 °. As a result of a powerful reflex effect on the fracture area with liquid nitrogen, pronounced vasomotor tissue reactions appeared within 1-3 minutes after the end of cryostimulation, which indicated an increase in blood flow in this zone. The temperature of the skin over the fracture was + 37.0-37.5 °. The increase in blood supply in the projection of the fracture, as can be seen from the data of the Doppler study (Fig. 6, 7) in the veins of the middle third of the leg (projection of the fracture) of blood flow. Figure 6 - on the 20th day after the fracture, before treatment to reduce blood flow. The wave amplitude is reduced, the phase is not traced. Blood flow is determined only during the period of systolic discharge. These phenomena of inferior blood supply are associated with persistent swelling of the soft tissues and the remnants of the hemorrhage that occurred at the time of the injury. In Fig.7 - the 30th day after the fracture, 7 days after treatment. The blood flow is close to normal, the biphasic wave of the blood flow is well traced, which indicates an improvement in the blood supply to the affected area, which created favorable conditions for an increased influx of nutrients and collagen conversion, contributed to the formation and introduction of capillaries into the resulting bone marrow, accelerating its maturation. The number of sessions was 6-10 daily procedures or exposure was carried out every other day. An increase in the degree of fixation of bone fragments was confirmed by an improvement in the well-being of patients and the appearance on the radiographs of a well-visualized bone callus 10-15 days after cryostimulation (Fig. 8).

The non-invasiveness and simplicity of the proposed method for the treatment of slow-growing fractures of long tubular bones makes it possible to carry out it in conditions close to outpatient. There were no complications during treatment (Table 1). The positive point was that during the cryostimulation of osteoreparative processes, the condition of soft tissues in the fracture zone improved significantly: the color of the skin, their turgor improved, inflammation in the wound area decreased, soft tissue reparative processes accelerated, which was apparently explained by the immunomodulating effect of cryotherapy.

Thus, the proposed method is not invasive, less traumatic, available on an outpatient basis, with massive lesions of the soft tissues, has a positive effect on their recovery, including enhancing the regeneration of neurovascular elements. With significant multi-fragmented diaphyseal fractures, when a good comparison of bone fragments is not always possible, the proposed method has an acceleration of osteoreparative processes, which significantly distinguishes it from known methods. At the same time, the advantage of the method is its analgesic and immunotherapeutic effect, which allows the most correct restoration of damaged tissue in the absence of any negative effect on the patient.

Information sources

1) Shapovalov V.M., Gritsanov A.I., Erokhov A.N. Slow Consolidation. False joint. Bone defect // Traumatology and orthopedics. St. Petersburg. 2004. S. 345-355.

2) Korzh N.A., Romanenko K.K., Goridova L.D. Reparative bone regeneration: a modern view of the problem. Impaired bone regeneration (message 2). // Orthopedics, traumatology and prosthetics. Kharkiv. 2006. No1. S.84-90.

3) Lavrishcheva G.I. On the possibility of influencing the rate of restoration of normal bone structure after a fracture and the principles of morphological assessment. // Medical rehabilitation of patients with bone fractures and orthopedic diseases. Collection of works CITO. Issue 26. Moscow. 1983. S. 6-10.

4) Lavrishcheva G.I., Onoprienko G.A. Morphological and clinical aspects of reparative regeneration of supporting organs and tissues. Moscow. The medicine. 1996.208 p.

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Table number 1 Name of delayed consolidation osteostimulation method Number of patients with diaphyseal fractures The timing of the formation of corn in the process of applying the method Complications during the treatment Negative results Conservative methods (medication, electrical stimulation, etc.) 7 20-35 days 2 (28.5%) (allergic reactions) 4 (57%) Beck Tunneling 8 15-25 days 3 (37.5%) (suppuration of hematomas) 3 (37.5%) Cryostimulation 12 10-15 days - -

Claims (1)

A method for treating fractures of long tubular bones, including reposition, mobilization of bone fragments and impact on the fracture zone, characterized in that after the edema subsides, they are exposed to cold, for which they first treat the skin area in the projection of the area with a cotton swab moistened with coolant until the skin is whitened slightly, and then a cryomechanical action is carried out by a porous movable roller of titanium nickelide filled with liquid nitrogen over the skin surface in the projection of the fracture zone by reciprocating movements for 7-1 0 min, and at first, during 3.5-5 min, making movements in the longitudinal direction, and in the rest of the time, making movements in the transverse and oblique directions, then, alternating them alternately, the course includes 6-10 sessions conducted daily or through day.

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