RU2391068C1 - Method of treatment of distal periarticular fractures of humeral bone - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to orthopedics. Two identical pins for osteosynthesis are used which are bent before the installation and are inserted retrogradely through established channels intramedullary. At that hard lockable pins of nonwoven synthetic fabric of 4 mm in diametre with an extension at the distal end of 6 mm in diametre. The proximal ends of the pins with holes for blocking are removed. The length of each pin is purchased no less than the sum of four lengths of the shoulder peripheral fragment and the distal parts of the pins are left straight for the distance equal to one and a half length of peripheral fragments of the shoulder. The points for the pins insertion on the bottom surface of condyle of humerus are elected stepping 15 mm back from the outer edges of the condyles to the humerus axis. Each pin is blocked distally with two screws in the sagittal plane through the navigation system. Then a proximal blocking is conducted with a screw of 3.5 mm in diametre, sending it from behind anteriorly along the line formed by the intersection of the sagittal plane passed through the longitudinal axis of the humerus and the transverse plane made in intramedullary canal. The method of "free hand" is used during insertion of proximal locking screw. Screw-caps on the distal ends of the pins are placed.

EFFECT: method provides a stable osteosynthesis, the possibility of early functional loads, shorter recuperation period.

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Description

The invention relates to medicine, namely to orthopedics, and is intended for the treatment of distal periarticular fractures of the humerus.

Known methods for osseous osteosynthesis of distal periarticular fractures of the humerus with two lockable or non-lockable plates (one third of a tubular plate and a small straight reconstructive), metaphysical straight lockable plate, various modifications of lockable and non-lockable “Y” -shaped plates [Mueller M.E. Allgover M., Schneider R., Willinger X. Guide to internal osteosynthesis. The technique recommended by the AO group (Switzerland. - Springer - Verlag Ad Marginem. - 1996, p. 48-45; Catalog of the SYNTHES company. Original instruments and implants developed by the International Osteosynthesis Association. - AO / ASIF. Plate system with angular stability LCP. Osteosynthesis without compromise; Bulletin Margo Anterior. 2006 No. 3. C.6; Product catalog NPO DEOST. 2009. P.31] The disadvantages of these methods of bone osteosynthesis are: forced increase in the area of coverage of the cortical surface of the bone with metal structures and the general volume of metal in order to compensate for the loss of fixation strength, to reduce the likelihood of fatigue fractures of metal structures, due to the distance from the center of distribution of loads on the bone, to achieve the necessary stability and stress at the fracture site, necessary for early functional loads and for fusion, as well as loss of stability during slow fusion a fracture against the background of advanced bone resorption in places of contact with metal structures, often arising the need for identification and isolation in the area of surgical access pa surrounding nerve bone, increase the recovery time of the gliding apparatus.

The known technique of intramedullary osteosynthesis of distal periarticular fractures of the humerus with two elastic non-blocking titanium TEN pins, taken as a prototype [Bulletin Margo Anterior. 2000, No. 3. C.8. Section New Products; Catalog of the company SYNTHES. Original instruments and implants developed by the International Osteosynthesis Association - AO / ASIF. Products for intramedullary osteosynthesis. Basic systems. C.5]. The disadvantages of this method are: Initial rotational instability, insufficient lateral and angular stability, insufficient axial stability that impedes tensile forces, as well as possible technical difficulties associated with the loss of repositioning anatomy during installation due to the difficultly predicted direction of the total force vector created by two elastic non-blocking titanium pins TEN voltage. All these deficiencies are all the more pronounced the more distally located, and the less stable the location of the fracture of the humerus.

The technical result is the achievement of multi-plane, including rotational and to breaking strength stability with the creation of stress forces at the fracture site, the possibility of early functional loads and burdened loads, stability with anticipatory resorption around the metal structures in cases of prolonged fracture fusion due to trophic disturbances in place shoulder injuries of various origins, reducing the risk of damage to the great vessels and nerves, simplifying the achievement of anatomical reposition, shortening the recovery period of the apparatus with ringing.

The proposed method is as follows. At the stage of preoperative planning on the basis of preoperative radiographs (Fig.1-2), perform a fracture level diagram (Fig.3) and a diagram of the standing of the fragments in the preoperative period (Fig.4). Choose two identical in all properties intramedullary lockable pins SNM with a diameter of 4 mm with an extension at the distal end with a diameter of 6 mm made of steel ISO 5832-1. Remove the proximal ends of the pins, weakened by the presence of holes for proximal blocking (figure 5). The length of each pin prepared for installation should be at least the sum of the four lengths of the peripheral fragment of the shoulder. They plan proximal intra-channel blocking of both pins with a 3.5 mm screw and distal blocking of each pin with two 1.5 mm screws in the sagittal plane of the shoulder, so the pins are bent in a plane perpendicular to the holes for distal blocking, taking into account the planned trajectory of reaming in the bone of the channel for installing the pins , are guided by the X-ray of the distal section of the injured shoulder in direct projection (figure 1). The distal parts of the pins are left unbent for a length equal to one and a half lengths of the peripheral fragment of the shoulder in order to obtain stable stress metal osteosynthesis after the installation of the pins.

After processing the surgical field through a longitudinal linear section from the point of fracture of the shoulder to the projection of the base of the ulnar process along the midline of the posterior surface of the upper limb “Y”, the triceps muscle of the shoulder and the back of the joint bag of the elbow joint are cut through all layers to the bone (Fig.6) . Allocate a break point. Soft tissues subcortically exfoliate and push apart to the sides and thus skeletonize the condyles of the shoulder along the posterior and lower surfaces. The points for retrograde holding of the pins on the lower surface of the condyles of the shoulder are selected by retreating 15 mm from the outer edges of the condyles to the axis of the humerus. An 8 mm channel is drilled from the lower surface of the condyles of the shoulder to the fracture site. The place on the fracture plane of the central fragment is determined, where the channels formed in the peripheral fragment of the shoulder fall. From the obtained points on the fracture plane in the central fragment, 6 mm channels are directed vertically and towards the longitudinal axis of the bone towards the medullary canal (Fig. 7). The fragments are compared, both pins are installed at the same time. Distal blocking is made in the sagittal plane with two 1.5 mm screws of each pin through the navigation system. Proximal blocking is performed with a screw with a diameter of 3.5 mm, directing it anteriorly along the line formed by the intersection of the sagittal plane drawn through the longitudinal axis of the humerus and the transverse plane drawn at the intersection of the pins in the intramedullary canal, using the method " free hands. " Install the cap screws on the distal ends of the pins. Thus, they obtain multi-plane stability, including rotation and tear strength, with the creation of tension forces at the fracture site due to the elastic properties and the nature of the bending of the pins, which contribute to the fracture fusion and have a potential duration of action at the fracture site, even in the case of resorption around the metal structures . The final view after metal osteosynthesis is schematically depicted in Fig. 8. The wound is sutured in layers. Apply an aseptic dressing. Immobilization is used only in the case of initial contracture of the elbow joint until the moment when the patient can independently control the range of movements within the original limits.

The achieved degree of synthesis stability and the mechanical stress created by the interaction of the two pins in the bone provides the possibility of early functional loads and burdened loads, allows to maintain stability with anticipatory resorption around the metal structures in the case of prolonged fracture fusion due to trophic disturbances at the fracture site of various origins, and reduces the risk of damage to the main vessels and nerves, simplifies the achievement of anatomical reposition, reduces the recovery time of the apparatus that slip.

The invention is illustrated by the following figures: figure 1 shows a radiograph of the lower third of the shoulder in a lateral projection to intramedullary blocking metallosynthesis; figure 2 is the same in a direct projection; figure 3 - diagram of the level of transverse supracondylar fracture; figure 4 is a diagram of the standing of fragments of an overgrown distal periarticular fracture of the humerus to the intramedullary blocking osteosynthesis; figure 5 is a standard lockable pin SNM with a diameter of 4 mm with a thickening in the distal end of 6 mm with screws for distal locking with a diameter of 1.5 mm, and for proximal intrachannel blocking of both pins screw 3.5 mm in diameter. A line is shown at the level of which the standard SNM pins break off, which in normal practice are intended for intramedullary blocking metal osteosynthesis of the bones of the forearm and tibia; Fig.6 is a diagram of a skin surgical incision and an operating "Y" -shaped longitudinal section of the triceps of the shoulder and articular bag; Fig.7 is a diagram of the formation of the channels of the Central and peripheral fragments of the humerus before installing the lockable pins; on Fig - the final view after installing the pins, locking them and installing the screw caps on the distal ends of the pins; Fig.9 is a diagram of the stress forces obtained as a result of metal osteosynthesis with two lockable pins in the humerus; figure 10 - x-ray of the lower third of the shoulder in a lateral projection after intramedullary blocking metallosynthesis of the shoulder with two pins; 11 is a radiograph of the lower third of the shoulder in direct projection after intramedullary blocking metallosynthesis of the shoulder with two pins.

Clinical example.

In May 2007, patient Sh., 34 years old, was operated on in the traumatology department of the Moscow State University of Internal Medicine in Ufa in several stages regarding a secondary open comminuted intraarticular fracture of the lower third of the left shoulder with a bruise of the ulnar and radial nerves. The first stage was performed by transverse rod metallosynthesis using the “Shoulder-forearm” apparatus. To improve soft tissue trophism, to heal primary wounds without inflammation, and to reduce neurological disorders, the second stage performed bone metal osteosynthesis of the lower third of the left shoulder with one third of the tube and a small straight reconstructive plate with fixation of the elbow process by Weber. The third stage removed the pivotal apparatus after the formation of primary bone callus. Discharged from the hospital without gross neurological deficit. The fourth stage in connection with the impingement syndrome after the joint of the fracture in 2008 removed the patient’s discomfort during movements in the elbow joint, the metal structures that fixed the ulnar process, and the screws that fixed the humerus block in a planned manner for medical reasons. Due to the peculiarities of professional activity, the patient did not find the opportunity for a full-fledged rehabilitation treatment. After the treatment, the patient maintained persistent flexion contracture with a limitation of extension of 150 °. According to the patient, in April 2008, he broke a tree from a jump, making hanging on his hands, making a tree, after which there was pain, swelling in the lower third of the left shoulder, the range of movements in the left elbow joint sharply increased. The patient did not seek medical help. Used a brace. Underestimated the injury, considering that there was a reduction of the elbow joint, until he paid attention to the growing deformation of the lower third of the left shoulder. He applied and was hospitalized in the traumatology department of the MU GGVV Ufa on 07/08/08 with an uncomplicated course of the injury 4 months after it was received at home. Upon admission, a survey was conducted with a plan for the removal of metal structures with simultaneous metal osteosynthesis of the left shoulder. 07/15/08 metal structures of the left shoulder were removed, intramedullary blocking metallosynthesis of the left shoulder was performed with two lockable SNM pins under conduction anesthesia. Operation description.

The position of the patient lying on his stomach with shoulder abduction of 45 °, with zero rotation of the shoulder, with flexion in the elbow joint of 150 °. After processing the surgical field through a longitudinal linear incision of 20 cm, from the border of the middle and lower third of the shoulder to the projection of the base of the ulnar process along the midline of the posterior surface of the left upper limb “Y”, the triceps muscle of the shoulder and the back of the joint bag of the elbow joint are dissected. Remove the fatigue-fractured plates with screws. Ignore the screw, which is surrounded by a scar and is located in the soft tissues anterior to the humerus, so as not to complicate the operation. Allocate a break point. The saw in the transverse plane is economically resected with the changed ends of the central and peripheral fragments. The control of the correctness of the sawdust is checked by the alignment of the fragments during the comparison. Soft tissues are subcortically peeled off and thus the condyles of the shoulder are skeletonized along the posterior and lower surfaces. The points for retrograde holding of the pins on the lower surface of the condyles of the shoulder are selected by stepping 15 mm from the outer edges of the condyles towards the longitudinal axis of the humerus. An 8 mm channel is drilled from the lower surface of the condyles of the shoulder to the fracture site. The place on the fracture plane of the central fragment is determined at the points where the channels formed in the peripheral fragment of the shoulder fall. From the obtained points on the fracture plane in the central fragment, 6 mm channels are directed vertically and towards the longitudinal axis of the bone towards the medullary canal (Fig. 7). The fragments are compared, both pins are installed at the same time. Distal locking is made with two 1.5 mm screws of each pin through the navigation system. Proximal blocking is carried out by a screw with a diameter of 3.5 mm, directing it anteriorly along the line formed by the intersection of the sagittal plane drawn through the longitudinal axis of the humerus and the transverse plane drawn at the intersection of the pins in the intramedullary canal, using the method " free hands. " Install the cap screws on the distal ends of the pins. The wound is sutured in layers. Apply an aseptic dressing. Do control radiographs (figure 10-11). The elbow joint is fixed with a hinged brace with freedom of movement in the hinges corresponding to the angles of passive joint movements obtained after metal osteosynthesis.

In the postoperative period, trophic disorders of the skin of the left shoulder in the form of serous epidermal blisters were quickly stopped. There were no vascular, neurological complications in the postoperative period. Edema on the 7th day after the operation ceased to be determined. The postoperative wound healed by primary intention without signs of inflammation. The patient was discharged after removal of the postoperative sutures in satisfactory condition with improvement, with a range of movements in the left elbow joint corresponding to the volume that existed before the injury received in April 2008. They recommended continuing immobilization with a hinged brace for 6 weeks from the moment of surgery, continuing physical therapy, not trying to increase the initial range of motion in the elbow joint until the fracture was healed, and treating post-traumatic osteoporosis of the left shoulder. The patient is engaged in small business. Work is not associated with physical activity on the upper limbs. After discharge from the hospital, the patient proceeded to work.

Claims (1)

A method for surgical treatment of distal humerus fractures, including osteosynthesis using two identical pins, which are bent before installation and carried out retrogradely through the formed channels intramedullary, characterized in that they use rigid lockable pins of the SNM with a diameter of 4 mm with an extension at the distal end with a diameter of 6 mm, removed the proximal ends of the pins with holes for blocking, the length of each pin is chosen at least the sum of the four lengths of the peripheral fragment of the shoulder and left unbent the distal parts of the pins are spaced for a length equal to one and a half lengths of the peripheral fragment of the shoulder, the points for holding the pins on the lower surface of the condyles of the shoulder are selected, 15 mm apart from the outer edges of the condyles to the axis of the humerus, distally each pin is blocked with two screws in the sagittal plane through the navigation system, after which proximal blocking is performed with a screw with a diameter of 3.5 mm, directing it anteriorly along the line formed by the intersection of the sagittal plane drawn through the longitudinal axis of the shoulder to spine, and the transverse plane drawn in the intramedullary canal, using the “free hand” method during the proximal locking screw, after which the cap screws are installed on the distal ends of the pins.

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