RU2333727C1 - Method of primary reparative surgical treatment of long bones gunshot fracture in present local military conflicts - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to traumatology and military field surgery, and can be used for primary reparative gunshot fracture of long bones followed by injury of main artery and nerve. Facsiotomy of muscular fascial compartment of limb segment is carried out. Devitalised tissues are resected. The bones are treated, free bone fragments are removed. Main artery is restored by auto venous plastic reconstruction. The injured nerve is treated along both its ends by neurolysis. Neuroma is threaded by synthetic thread. The ends of thread are output on skin. Each of thread ends is fixed in external fixator installed on backstop of Ilizarov apparatus. With 2-3 days after the surgery, distraction of each nerve end is carried out in a direction corresponded to the nerve by removing of ligature in the external fixator till the nerve length which is necessary for recovery. The ends of nerve are stitched.

EFFECT: decrease of medical evacuation stages quantity, restoration of all injured structures and limb function.

2 cl, 2 ex

Description

Currently, there is no doubt that the primary method of treating gunshot fractures is primary surgical treatment (GKO), however, the views on its goals, scope and sequence are contradictory.

If in the XIX century. and previously it was only prescribed to dissect a gunshot wound and to drain, then during the First World War it was firmly established that the presence of non-viable tissues in the wound promotes the development of wound infection and therefore it was proposed to “carefully excise them” [4], including in the case of gunshot fractures the humerus.

During the Second World War, according to a number of authors [3, 5, 6, 21], it was prescribed to dissect the wound along the damaged segment, excise all non-viable tissues, and remove freely lying bone fragments [1 - 3, 7, 13, 15, 19]. Thus, radical operations were performed, accompanied by a significant removal of tissues, which in some cases led to irreparable loss and consequently disability. Naturally, such a tactic at a time when there were no potent antibiotics and antiseptics, in conditions of mass admission of the wounded, could be recognized as correct, but the functional and cosmetic results were not always acceptable.

The decades that have passed since the Second World War have made significant adjustments regarding the methods and scope of PWS. Studies of the morphofunctional structure and pathophysiological features of a gunshot wound have convincingly shown that the generally valid principle of “overtaking the infection with a knife” is now filled with new content - with the maximum preservation of viable tissues and the restoration of the anatomical structures of the damaged limb segment [16 - 18, 20].

The experience of past local wars, in particular the hostilities in Vietnam, Afghanistan and the Chechen Republic, allowed some changes to be made to the surgical treatment of gunshot fractures. During the world wars, in contrast to local military conflicts, due to many factors, the initial surgical treatment of wounded in the limbs was reduced to the toilet of wounds and surgical interventions at the level of qualified surgical care, which were accompanied by a significant number of complications and, accordingly, high disability. In local wars, the number of wounded was significantly reduced, their simultaneous admission to the stages of surgical care was reduced, the provision of medical services by forces and means was improved, which made it possible to perform modern primary reconstructive surgical interventions and naturally improve treatment outcomes.

So, comparing the system of surgical care at the first stage of the war in Afghanistan with the subsequent one, after 1982-1983, when elements of primary reconstructive interventions for gunshot injuries of the extremities were introduced, as well as with the first period of hostilities in Chechnya, when the bulk of the wounded arrived in a short time in the central hospitals of the Ministry of Defense of the Russian Federation, where they also underwent primary reconstructive treatment, we can state the correctness of such a conclusion [8 - 12, 14].

Naturally, a decrease in the number of stages of medical evacuation, in which the wounded receive appropriate surgical care, is also positive. So, in the first period of the Afghan conflict, the wounded went through an average of 6-8 stages of medical care, and in Chechnya their number dropped to 2-3.

Thus, the constantly changing attitude to the surgical treatment of gunshot fractures made it possible to determine that its basis is the primary surgical treatment, which seems to be a complex and crucial operation, ultimately deciding the fate of the wounded. The historical pathway of the development of PHC can be traced from simple dissection of tissues to primary reconstructive operations, from superradical excisions to organ-preserving interventions. Naturally, the achievements of modern methods of surgical treatment required the introduction of modern technologies, which include both the achievements of classical reconstructive surgery and rational microsurgical techniques. Nevertheless, many of the most important issues of surgical tactics in the treatment of this combat pathology remain controversial and require further systematization and ordering.

Of course, that the primary reconstructive reconstructive surgical treatment requires appropriate training of the surgeon who is to perform it, including theoretical, appropriate planning and organization. It should be borne in mind that primary reconstructive treatment is a complex intervention on which the fate of the wounded depends.

Therefore, a method of primary reconstructive surgical treatment for gunshot fractures of long bones of the extremities is proposed, including access passing through the wound canal and in the projection of the neurovascular bundle and performing the following actions during one surgical intervention:

- produce a fasciotomy of the muscle-fascial cases of the limb segment,

- obviously non-viable tissues are excised,

- treat the bone, remove free bone fragments,

- restore the main artery by autovenous plasty: as an autovenous graft, use the portion of the large or small saphenous vein of the femur where part of the adventitia is removed, after the resection of the ends of the damaged main artery, the graft is inserted into the defect so that its peripheral end adjoins the central end of the artery , produce a suture of the ends of the graft and artery according to Carrell,

- treat the damaged nerve by neurolysis of both its ends for a while, stitch the neuroma with synthetic thread, bring the ends of the thread to the skin and fix each of the ends of the thread in a spoke mounted on the support of the Ilizarov apparatus, superimposed on the damaged segment of the limb,

- during the entire operation, the area of surgical intervention is washed with antiseptic solutions by constant drip irrigation using a transfusion system.

Then, for 2-3 days after the operation, the distraction of each of the ends of the nerve begins in the direction corresponding to the course of the nerve by moving the ligature in the specifier to the length necessary to restore the nerve, and then the nerve suture is performed.

Optimal for distraction of the nerve ends is the following mode:

- the distraction of each of the ends of the nerve is carried out at a rate of 1 mm per day, in 4 doses, 0.25 mm for each dose.

It is advisable to dwell in more detail on the description of the proposed method.

At the stage of specialized surgical care in the preparatory period, along with the preparation of the skin, infusion therapy is carried out aimed at removing the wounded from shock, replenishing blood loss, correcting homeostasis disorders, stopping macro- and microcirculatory disorders.

The preparation of the wounded is combined with the planning of surgical treatment. The duration of this period depends on the condition of the wounded and the type and severity of the wound. When planning initial reconstructive rehabilitation treatment, the localization and nature of the gunshot fracture, the presence of concomitant injuries of the main vessels and nerves, the condition of adjacent joints, the completeness and quality of care at the previous stages of medical evacuation are taken into account. Naturally, the state of the wounded and the presence of combined and multiple injuries are the most important element for the final decision.

Thus, the choice of a particular surgical tactic in the treatment of injured with gunshot fractures is determined by the following factors: the general condition of the wounded, the nature and severity of the combined wounds and diseases, the time elapsed after the wound, the nature of the assistance at the previous stages of medical evacuation, the presence and nature general and local infectious complications, the condition of the skin in the paravual region, the nature of the gunshot fracture and the degree of destruction of the bone, soft tissues, localization fracture, the presence of damage to the main vessels and nerves, the condition of adjacent joints.

Briefly commenting on the foregoing, it should be noted that the most important and determining the entire course of further treatment is the stabilization of the general condition of the wounded. No surgical measures are performed until the wounded is taken out of shock, replenishment of the BCC, correction of metabolic disorders, relief of macro- and microcirculatory disorders. An exception is only a temporary stop of external bleeding, carried out according to generally accepted rules using a tourniquet.

Reconstructive surgery is carried out to the wounded in the limb, either according to urgent indications, or in a planned manner. In case of emergency surgery, preoperative preparation and examination are carried out within 3.5-6 hours after admission. In the absence of urgent indications, surgical treatment is performed as planned. In both cases, surgical treatment is carried out in the form of reconstructive surgery with all its inherent elements.

Indications for reconstructive surgical treatment according to urgent indications for gunshot fractures are the following: admission of the wounded without primary surgical treatment or its execution with defects, damage to the main vessels and nerves, as well as their compression, vicious position of bone fragments, extensive bone and soft tissue defect, development general and local purulent complications.

The fundamental condition for a full reconstructive surgical treatment for a gunshot fracture of a long bone is stabilization of the general condition of the wounded. A set of measures aimed at achieving this goal includes infusion therapy, which includes intravenous administration of colloidal and crystalloid solutions in the amount of 1200-1500 ml, protein preparations, blood transfusion, which uses red blood cells, whole fresh heparinized blood, freshly frozen plasma, antistaphylococcal plasma and other components and blood products in a volume of 800-1200 ml. Mandatory for this preparatory period is adequate pain relief. The duration of preparation for the operation ranges from 2-3 hours to several days, depending on the severity of the wounded condition and the severity of local changes, as well as on the stage of medical evacuation and the characteristics of the combat situation.

In order to create the most favorable conditions for wound healing, fracture consolidation and a good functional result both in case of emergency and planned surgical intervention, one should strive to restore all anatomical structures.

The main elements of reconstructive surgery are full access, fasciotomy, excision of clearly non-viable tissues, bone treatment, the most complete restoration of all damaged anatomical structures, including vessels and nerves, drainage, adequate drainage, if possible removal of foreign bodies, immobilization, etc. .d. In order to exclude additional blood loss, surgery is performed under a tourniquet.

Access is an essential element of primary reconstructive treatment. It can be performed by dissecting an existing wound or through intact tissues. Preference should be given to figured access, which allows to widely open the wound canal and to perform a full audit and surgical treatment of the damaged segment. In addition, access should create conditions for closing the wound with full flaps without tension, which is one of the conditions for uncomplicated healing of a gunshot wound.

The most important technical technique is the abundant washing of a gunshot wound with a large number of antiseptic solutions, which allows you to remove tissue detritus and foreign bodies, reduce microbial contamination of damaged tissues. This technique is carried out by continuous drip irrigation during a surgical operation using a conventional transfusion system.

No surgical intervention can do without a full subcutaneous fasciotomy of the muscle-fascial cases. Fasciotomy is an essential element of surgical treatment. In this case, all muscular-fascial cases of the shoulder should be dissected subcutaneously throughout. This surgical technique, aimed at decompressing the muscles, blood vessels, and nerves of the damaged segment, helped to improve microcirculation in the tissues, and therefore, reduced the likelihood of developing ischemic complications, secondary necrosis, and purulent complications. In addition, fasciotomy allows for a more complete audit of damaged tissues, improving the orientation of the surgeon in the wound.

During surgical treatment should be as careful as possible to the tissues of the limb. Only apparently non-viable tissues are excised. Doubts about non-viability are resolved in favor of less tissue removal. At the same time, it is necessary to strive for a complete revision of the wound and paravular tissue in order to identify foci of necrosis located in areas remote from the wound canal.

Particular care must be taken to bone fragments, which are rarely removed. The removed bone fragments are thoroughly washed and boiled; subsequently, after the stabilization of the condition of the wounded, they are placed in the subcutaneous tissue of the lower abdomen or in the intermuscular space between the large and middle gluteal muscles for subsequent bone grafting - for those cases when the site of the gunshot fracture remains a bone defect and subsequently osteoplastic surgery may be required.

During the surgery, various foreign bodies (bullets, metal fragments, scraps of uniforms, etc.) are removed. However, a special search for metal foreign bodies located in the distance is not carried out except in those cases when the latter compress the main vessels and nerves. The primary suture is not performed, except in cases of restoration of blood vessels and nerves, when mandatory closure of the wound by local tissues is required.

The most important element of the primary reconstructive surgical treatment of gunshot fractures that completes each intervention is wound drainage. 2-3 wide silicone double-lumen tubes are used, which are installed in the flat places of the wound. Drainage is carried out both in a flow-aspiration mode with 3-4 liters of aseptic fluids with antibiotics for 7-10 days, and actively with a vacuum of up to 50-100 mm aq. At the stage of providing qualified surgical care, it is advisable to conduct active aspiration in connection with the subsequent transportation and the lack of conditions for flow-aspiration drainage.

One of the most difficult questions facing surgeons during surgical treatment was the choice of a method for immobilizing bone fragments. In most cases, therapeutic immobilization is carried out by a deaf plaster cast. Primary bone osteosynthesis should not be used in the practice of field surgery. According to our data, most cases of bone osteosynthesis ended unsuccessfully. Mostly the wounded in these cases developed purulent complications of varying severity.

Extra-focal osteosynthesis with Ilizarov spoke devices is optimal for gunshot fractures with extensive bone and soft tissue defects in cases of damage to the great vessels and peripheral nerves.

The treatment of these injuries is one of the most difficult sections of the primary reconstructive restoration in case of gunshot fractures. Wounded with damage to the main artery are subjected to surgical intervention in the first place, which was the key to their successful treatment. The decision on treatment tactics is made comprehensively, taking into account the type of vessel damage, the time of limb ischemia, the presence of combined injuries and the condition of the wounded, the characteristics of the combat situation and the availability of forces and means of medical service.

Assessment of limb viability and diagnosis of damage to the great vessels is based on an assessment of the totality of all symptoms, including impaired sensitivity and movements, external bleeding, and pulsation in the peripheral parts of the limb. By importance, signs of damage to the main vessel can be located in the following order:

- the location of the neurovascular bundle in the projection of the wound channel;

- profuse continuing arterial bleeding;

- rapid increase in limb volume, pulsating hematoma;

- a decrease in limb temperature, cyanosis or pallor of the skin;

- the absence or significant weakening of the pulse on the peripheral parts of the limbs;

- hyposthesia and anesthesia of the distal extremities;

- muscle spasm and contracture of the distal extremities.

Indications for the restoration of the great vessels on the extremities are all their injuries, with the exception of developing limb gangrene. Surgery is performed only after resuscitation and anti-shock measures against the background of a temporary stop of bleeding in the presence of trained personnel and technical equipment in a favorable medical and tactical situation. If the necessary conditions are absent, temporary artery bypass surgery is performed, which allows to avoid irreversible limb ischemia until the general condition of the wounded is stabilized or before evacuation to the stage of specialized care.

The technique of temporary prosthetics is that after isolation and economical resection of the ends of the vessel, its defect is replaced by a silicone or PVC tube from the blood transfusion system, which is fixed in the lumen of the vessels by a circular ligature.

PHW of gunshot fractures with a wound of the main artery has its own characteristics. Surgery is performed under a tourniquet. Of great importance is the choice of the correct access, which, as a rule, is shaped and passes through the wound canal and in the projection of the neurovascular bundle, taking into account the possibility of subsequent closure by the muscles of the site of the anastomosis and neurovascular bundle. Fasciotomy is a mandatory step in the intervention, as it subsequently reduces the degree of limb ischemia and allows more free manipulation in the wound. The artery is secreted throughout, pinched by the terminals. A vessel defect of up to 2 cm in length allows the primary suture of the brachial artery to be performed. For more extensive defects, autovenous plastic is performed.

This surgical intervention consists of several stages, each of which has its own characteristics. As an autovenous graft, a section of the large saphenous vein of the femur is used, on which part of the adventitia is removed and the collaterals are ligated. After resection of the ends of the damaged vessel, the graft is introduced into the defect so that its peripheral end adjoins the central end of the artery, thereby creating acceptable conditions for blood flow without disturbing the valve system in the venous graft. The seam of the ends of the graft and artery is made according to Carrell. As suture material, synthetic thread No. 5 \ 0-6 \ 0 is used.

The restored neurovascular bundle is covered by displaced muscles. Drainage is carried out in such a way that the drainage tubes do not have direct contact with the anastomotic zone and neurovascular formations. The wound necessarily closes primarily with the help of plastic oncoming flaps. Fragments of the bone are fixed with a plaster cast or in an external fixation apparatus.

In the postoperative period, direct anticoagulants are administered to the wounded - heparin at 5000 IU six times a day intravenously under the control of blood coagulation time, antispasmodics, antiplatelet agents and rheologically active solutions. Drainage is carried out in a flow-aspiration mode for 3-6 days against a background of antibiotic therapy. Extremities are given an elevated position, local hypothermia is used.

The recovery of peripheral nerves during gunshot wounds is extremely important, including for social rehabilitation. Experience shows that in cases where the main nerve does not recover, the limb loses more than 30-40% of its working capacity and in many cases becomes a cause of disability. In addition, the lack of innervation leads to delayed wound healing, impaired microcirculation and more frequent suppuration. Therefore, there is a reasonable need for the full restoration of gunshot injuries of nerves. It turns out that in most cases this is possible during the initial surgical treatment. The primary restoration of nerves is performed in the following order: the ends of the nerve trunk are extracted and economically resected, a 2.4% solution of aminophylline in 0.25% novocaine solution is injected intravenously, then a perineural suture is performed. In those cases when simultaneous restoration is impossible due to the extent of the defect, resort to the transposition of nerves. In cases of the most extensive (more than 3 cm) defects, a two-stage distraction restoration of nerves is performed with a subsequent suture. In the latter case, after neurolysis of both ends of the damaged nerve during the neuroma, it is stitched with a strong synthetic thread, the ends of which are displayed on the skin and each end of the thread is fixed in a special fixator mounted on the support of the Ilizarov apparatus. 2-3 days after the operation, microdistraction begins at a speed of 1 mm per day in the direction corresponding to the course of the nerve from two sides to the length necessary for nerve repair, after which a delayed suture is performed according to the generally accepted method.

The use of a ligature for traction of a nerve with fixing its ends in special fixators on the Ilizarov apparatus is used for the first time in clinical practice. This method of nerve traction is more reliable, less traumatic, reduces the risk of nerve damage when it is pulled, more reliably fixes the nerve during patient movements with Ilizarov’s apparatus on a damaged limb.

Clinical example 1. Wounded M., 26 years old, received a gunshot comminuted fracture of the humerus in the middle third, damage to the brachial artery and nerve with severe motor, sensory and trophic disorders.

11.16.03 operated - primary reconstructive intervention was performed: fasciotomy, excision of obviously nonviable tissues, removal of free bone fragments, restoration of the artery by autovenous plastic, the damaged nerve was treated by neurolysis of both ends of the damaged nerve for a length of time, the neuroma was stitched with synthetic thread, the ends of the thread were brought to skin and fixed in special fixators in the Ilizarov apparatus. In the postoperative period, nerve distraction was performed until its required length was restored and a delayed nerve suture was performed. 2 years after the injury - the function of the limb in full.

Clinical example 2. Wounded A., 29 years old, received a gunshot comminuted fracture of the humerus in the lower third, damage to the brachial artery and nerve with severe motor, sensory and trophic disorders.

The primary reconstructive intervention was performed: fasciotomy, excision of obviously nonviable tissues, removal of free bone fragments, restoration of the artery by autovenous plasty, the damaged nerve was treated by neurolysis of both ends of the damaged nerve for a length of time, the neuroma was stitched with synthetic thread, the ends of the thread were brought out to the skin and fixed in special fixators in the Ilizarov apparatus. In the postoperative period, nerve distraction was performed until its required length was restored and a delayed nerve suture was performed. On examination, 1 year after the wound - the function of the limb is fully restored, there are minor disturbances of sensitivity on the forearm and hand.

The method of primary reconstructive surgical treatment of gunshot fractures can significantly reduce the time of treatment and rehabilitation, provide the ability to restore all anatomical formations of the lesion area, significantly reduce the risk of pseudoarthrosis, significantly reduce the risk of limb amputation, and ensure full restoration of limb function.

Bibliography

1. Alekseeva O.A. Treatment of gunshot fractures of the shoulder // Questions of military medicine. - Riga, 1945. - S.145-148.

2. Bayer A.I. Gunshot fractures of the humerus based on the material of the front evacuation hospital // Dis ... Cand. - Tashkent. - 1947. - 204 p.

3. Bishko B.L., Dobychin B.D. The course and treatment of gunshot shoulder fractures in the front and rear evacuation hospitals // Experience Sov. medicine in the Great Patriotic War. - M., 1952. - T.15. - S.260-275.

4. Voynich-Sanoyazhetsky A.R. Notes on the treatment of gunshot fractures of the humerus // Rus. - 1917. - T. 16, No. 1. - S.13-20, 31-33.

5. 3aykovskaya L.A. Gunshot fractures of the humerus, their treatment and outcomes based on the materials of the deep rear // Dis ... Ph.D. - Sverdlovsk, 1946 .-- 175 p.

6. Kazan A.A. Gunshot wounds of soft tissues of the upper limb and shoulder girdle // Experience ow. medicine in the Great Patriotic War. - M., 1952. - T. 14. - S.284-293.

7. Libov L.N. Gunshot fractures of the shoulder // Sat. Leningra. Krasnoarm. military hospital. - L., 1942. - P.8390.

8. Nikolenko V.K. Treatment of the wounded in the limbs amid massive blood loss // Mater. scientific - prakt. conf. doctors of the association. - Kabul. - 1985. - P.15-17.

9. Nikolenko V.K. On the treatment of gunshot wounds of blood vessels // Doctor. - 1995. - No. 5. S.23-25.

10. Nikolenko V.K., Tkachenko S.S. Combat injuries of the musculoskeletal system // Field Surgery. - M., 1996 .-- S. 271-301.

11. Nikolenko V.K. Diagnosis and treatment of gunshot injuries of the great vessels // Methodical recommendations. - M., 1997. - 20 p.

12. Nikolenko V.K. Gunshot wounds of the hand // M .: Medicine, 1999. - 232 p.

13. Tkachenko S.S., Nikolenko V.K., Erokhov A.N. General and local treatment of wounded with gunshot fractures at the stages of medical evacuation // Military-medical. journal - 1991. - No. 2. - S.24-24.

14. Tkachenko S.S.Gunnel diaphyseal bone fractures // Orthopedics, traumatology and prosthetics. - 1981. - No. 3. - S. 5-10.

15. Almskod B.A., Huljamae H., Hasselgren P.O. Local Metabolic changes in subtal muscle following high-energy missile injury // J. Trauma. - 1982. - V.22, No. 5. - P.383-387.

16. Brannon J.K., Woods C., Chandran R.E. Gunshot wounds to the elbow // Orthop.Clin.North Am. - 1995. - V.26, No. 1. - P.75-84.

17. Danon J.L., Dolev E. Primary treatemant of battle casualtes in the Lebanon War, 1982 // IsrJ.Med.Sci. - 1984. - V.20, No. 3. - P.300-302.

18. Eiseman B. Combat casualty management in Vietnam // J. Trauma. - 1967. - V.7, No. 1. - P.53-63.

19. Fosse E., Husum H., Giannou C. The siege of Tripoli 1983: War surgery in Lebanon // J. Trauma. - 1988. - V.28, No. 5. - P.660-663.

20. Halbert R.J., Simon R.R., Leshuk L. Logistic of medical care in rural Agghanistan // Ann.Emerg.Med. - 1988. - V.17, No. 8. - P.770-774.

21. Hughes J.L. Gunshot fractures // Milit.Med. - 1986. - V.141, No. 6. - P. 48-53.

Claims (2)

1. The method of primary reconstructive surgical treatment of gunshot fractures of long bones, accompanied by damage to the main artery and nerve, characterized in that they access through the wound canal and in the projection of the neurovascular bundle; during one surgical intervention, they perform the following: perform fasciotomy muscularly - fascial cases of a segment of a limb, obviously non-viable tissues are excised, bone is treated, free bone fragments are removed, master is restored autologous venous artery by transplantation: a portion of the large or small saphenous vein of the femur is used as an autogenous graft, where part of the adventitia is removed, after the resection of the ends of the damaged main artery, the graft is inserted into the defect so that its peripheral end adjoins the central end of the artery and sutured the ends of the graft and artery according to Carrell, treat the damaged nerve by neurolysis of both ends for a length, stitch the neuroma with synthetic thread, the ends of the thread are brought out onto the skin and each of the ends of the thread is fixed in a special fixator mounted on the support of the Ilizarov apparatus, superimposed on the damaged segment of the limb, during the whole operation they wash the area of the surgical intervention with antiseptic solutions by constant drip irrigation, 2-3 days after the operation begin to distraction each of the ends of the nerve in the direction corresponding to the course of the nerve by moving the ligature in the retainer to the length necessary for restoration of the nerve, after which the ends of the nerve are sutured. 2. The method according to claim 1, characterized in that the distraction of each end of the nerve is carried out at a rate of 1 mm per day, in 4 doses, 0.25 mm for each dose.