RU2460484C1 - Method of early rehabilitation of children with fractures of lower extremities - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to traumatology and orthopedics and is intended for early rehabilitation of children with fractures of lower extremities. Full imitation of support load is performed from the first day after surgery by means of sole simulator of support load "Korvit", with the child getting 8-10 procedure at rate 120 steps/ min, which corresponds to "average walking" mode with step duration 500 milliseconds and pressure in pneumoorthresis cusion 20 kilopascals, with 10 minute duration.

EFFECT: method makes it possible to reduce pain and edema, improve psychoemotional state of child, contributes to preparation of musculoskeletal and ligamentous-muscular apparatus for supportability, early recovery of walking, which facilitates patient's state on the whole.

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Description

The invention relates to medicine, namely to traumatology and orthopedics, and is intended for early rehabilitation of children with fractures of the lower extremities.

In recent years, with the advent of extreme sports (snowboards, skateboards, parkour), the number of fractures of the lower extremities in children by the “adult type” (multiple, segmental, multi-split, double) has increased. The recovery time after such fractures increased by 2-2.5 times, which significantly lengthens the time of rehabilitation treatment and rehabilitation of children and the period of disability of parents to care for the child.

A device for intermittent pneumocompression (apparatus KF-01-Nazeli LLC CMS-TEYD, Russia), which is used at the early stage of rehabilitation of adult patients with fractures of the lower extremities. The device helps to reduce pain, accelerates the removal of soft tissue edema of an injured limb (E. A. Chukina, V. A. Schetkin, I. Yu. Klyukvin, “Physiotherapy, Balneology and Rehabilitation”, 2010, No. 3).

A well-known apparatus for rhythmic pneumatic compression - APKU-5 or RPKU-5 (registration number 92 / 136-56 State register of medical devices, Moscow, Ministry of Health, 1996), operating in a descending "traveling wave" mode with simultaneous pressure relief in sections cuffs for the treatment of patients with chronic obliterating diseases of the arteries of the lower extremities. The device is recommended for patients with distal lesions of the arteries of the lower extremities as a preoperative preparation of the vascular bed (E. M. Lipnitsky, G. G. Amosov, K. M. Morozov, “Angiology and Vascular Therapy”, 2007, No. 3, p.22 -26).

There is a method of complex rehabilitation treatment of fractures of the lower extremities with the help of active physical exercises and passive movements in the joints performed by the patient or physical therapy practitioner, using an orthopedic bed with a mechanical drive, which also includes massage, paraffin or ozokeritotherapy, mud therapy (M.A.Zhanaspaev , “Functional rehabilitation treatment of unilateral fractures of the femur and lower leg bones”, Ph.D. Candidate of Medical Sciences, 1996).

A device is known - a robotic vertical table GR-9900 (Korea) with the function of passive movements of the lower extremities, designed to accelerate the rate of early rehabilitation in bed patients with neurological disorders. Asymmetric mode allows you to adjust the range of motion for each lower limb separately (http://www.reab-l.ru/index.php?page=products&pid=533).

The disadvantage of this expensive bulky device is that the table does not sparingly simulate the supporting load, and in the first postoperative days it is contraindicated due to the threat of increased soft tissue edema, lymphostasis and pain.

A device for restoring the health of joints of a person is known, consisting of a frame, a reversible electric drive connected to a screw pair in the form of a lead screw and nut, transmission, two lodgements and support for the foot (RF Patent No. 2281077). The device is not intended to perform the initial supporting load, it has only a support for the feet, the ankle joint does not work in it and the possibility of afferent stimulation disappears.

A device is known for stimulating reparative regeneration of bone tissue (RF Patent No. 2213589), in which a low-frequency pulsed effect occurs only in the damage zone.

It is known to use electromyostimulation with interference currents in combination with therapeutic gymnastics of an injured limb using the INTERDYN ID 79 M serial production device (Poland) for the purpose of analgesic action, reduction of edema, and improvement of the neuromuscular apparatus of a damaged limb (E. A. Chukina, “Complex rehabilitation treatment patients with fractures of the distal section of the bones of the leg and ankles ", dis. Cand. of Medical Sciences, 1997).

A known method of rehabilitation of patients with fractures of long bones, including exposure to the central nervous system by interference complexly modulated low-frequency pulse currents of a rectangular shape (RF Patent No. 2300401), which allows you to activate reparative processes in the fracture zone in the early and late rehabilitation periods.

The disadvantage of this method is that galvanization is used only for indirect exposure through the central nervous system to a damaged organism.

The Ilizarov apparatus is known, which is indicated for open fractures with bone defects, nonunion, suppuration, repeated surgical interventions, complete loss of support function of the limb, and only fixing the damage zone with a compression-distraction apparatus makes it possible to carry out rehabilitation treatment (Kasymov S.K. Experience treatment of bone fractures and their consequences by compression-distraction method // Compression-distraction method of treatment of traumatologic and orthopedic patients: Collection of scientific papers. Kent, 1987, s.26-28).

The apparatus for rehabilitation and myostimulation is known, which is an automatic device for continuous passive movements (NAP), designed to develop an ankle joint, prevent the negative effects of immobilization and return to the patient painless movements in the joints in the early period (http://www.ortorent.ru / equipment / artromotsp2). The device is used only in the post-immobilization period, as its use in the first postoperative days is contraindicated due to the threat of increased soft tissue edema.

A known method of reconstructive treatment of complicated fractures of the lower extremities, including dosed muscular work of a static or dynamic nature, in which they perform muscular work against the background of the action of centrifugal forces in the direction of the head - lower extremities. Muscular work of a dynamic nature is performed with power from 10 to 50 W with a gradual increase in muscle load and amplitude of movement in the joints of the affected limb, duration of sessions from 10 to 15 minutes, speed from 25 to 36 rpm. The therapeutic effect is carried out in 2-3 courses with an interval of 1.5-2 months, 15 procedures each. The method allows to optimize reparative osteogenesis due to increased blood supply with the regulation of venous outflow, helps to restore the range of motion in the joint (RF Patent No. 2146115).

The method requires significant cash, a large room, trained personnel. In children's practice, it is absolutely not applicable due to negative psychological effects.

This method is chosen by us as a prototype.

Currently, thanks to new technologies of minimally invasive metal osteosynthesis, gypsum immobilization is used in rare cases, therefore, it is possible to apply passive and active therapeutic exercises to an injured limb immediately after surgery, but without supporting load.

The objective of the present invention is to develop a less traumatic method for early rehabilitation of children with fractures of the lower extremities.

The technical result of solving the problem is to reduce the duration of the course of a traumatic disease, starting from the first day after the operation.

The essence of the method is to use the apparatus of the PION "Corvit" (Figure 1) (registration certificate No. FSR 2009/04901) for the early rehabilitation of children with fractures of the lower extremities from the first day after surgery at the age of 1.5 to 17 years.

The apparatus was developed at the Institute of Biomedical Problems to prevent the occurrence of "motion sickness" and its manifestations in the form of dizziness and illusions in astronauts in zero gravity. The clinical version of the simulator of the supporting plantar load - the KORVIT model - was developed by Center for Aerospace Medicine LLC together with the SSC RF-IBMP RAS based on the space prototype. The plantar support simulator Corvit is designed to simulate a “sensory image of walking” in the physiological mode of a walking cyclogram, activating a spinal locomotion generator and motor centers of a higher organization, it is indicated for the complex treatment of neurological patients and for the rehabilitation of patients with traumatic brain injury in conditions of decrease or complete absence of support loads. (http://www.diasled.ru/korvit2008.html http://www.amc-si.com/). The Corvit device simulates support reactions using the principle of pneumomechanical pressure on the corresponding supporting zones of the foot using special pneumatic chambers in the developed modes of real walking.

In our proposed method, each child received 8-10 procedures in the “average walk” mode at a speed of 120 steps / min, the step duration was 500 milliseconds (1 step time in milliseconds), while the pressure created in the receiver and pumped into the pillows of the pneumoortheses was 20 kPa (kilopascal), the duration of the procedure is 10 minutes. Control of edema reduction was carried out daily by somatometry and ultrasound. Control examinations were performed after 2 weeks, 1 and 2 months.

The procedures did not cause a negative reaction in children, they were positively welcomed due to the presence of pleasant sensations during their conduct. The effect becomes evident already on the 2nd – 3rd day, when the somatometric parameters are normalized, the edema decreases, the muscle tone is maintained, and the range of motion in the joints of the damaged limb is increased. There was a decrease in pain in the injured limb, an improvement in the functionality of the injured limb, an increase in the overall motor activity of the child, and an early transfer from bed rest to general mode. We did not observe any complications or negative effects. Movements in adjacent joints are restored by 5-7 days after surgery, axial load was allowed from 3-5 weeks, depending on age. Children walk almost immediately without limping and in a week can attend child care facilities.

The use of the Corvit apparatus for early rehabilitation of children with fractures of the lower extremities is not obvious for specialists in this field and has become possible thanks to a comprehensive approach to the treatment of lower limb fractures in children (surgery + early rehabilitation), with the widespread use of minimally invasive stable functional osteosynthesis without external immobilization.

Clinical examples of the method.

Example 1. Patient M., 4 years 6 months old, was admitted to the department of traumatology and disaster medicine of the Research Institute of NIHT with a transfer from the central hospital of the city of Zubov-Polyana, where he was delivered after an accident with a diagnosis of auto-injury, brain injury, concussion, closed fracture of the left femoral bones in the upper third with an offset. On examination, the state of moderate severity. The left lower limb is fixed with a plaster cast, there are no active movements, the attempt is sharply painful, there is no violation of innervation. After removal of the bandage, marked deformation of the left thigh in the upper third, swelling of soft tissues at the border of the / 3-s / 3 of the left thigh (+6.5 cm on the left) were noted. After 6 hours from the moment of admission, according to emergency indications, a closed reduction was performed under general anesthesia, Tenami minimally invasive metal osteosynthesis. After surgery, the difference in the volume of the hips decreased by 1 cm (+5.5 cm on the left). On the first day after the operation, pain was noted in the damage zone, there were no active movements in the limbs, soft tissue edema persisted (+5.5 cm on the left). Early rehabilitation measures have begun: activation and exercise therapy in the bed, the first session of simulating the supporting load by the Corvit apparatus was performed (Figure 2 and Figure 3).

The course PION Corvit No. 10 was assigned in the “average walking” mode with a speed of 120 steps / min, the step duration is 500 milliseconds, the pressure in the pneumoestheses is 20 kPa (kilopascal), the duration is 10 minutes. On the 2nd day, pain in the projection of the fracture decreased, movements in the knee joint: extension reached the norm - 180 degrees, flexion 130 degrees, in the ankle joint in full. On the 3rd day, minor pain was observed in the fracture zone, increased movement in adjacent joints (flexion and extension in the hip joint of 45 degrees, in the knee joint: extension of 180 degrees, flexion of 90 degrees), edema decreased (+4.5 cm to the left ) The patient is upright. A child with his mother is engaged in a play with the other children. By 6 days the pain does not bother, the child is active, positively tuned, movements in adjacent joints in full, swelling has decreased (+3 cm), walks on walkers without resting on a damaged limb, is fully adapted, and goes to the playroom on his own. On the 9th day after surgery, the child is active, independent, positively tuned, movements in adjacent joints in full, swelling decreased (+2.5 cm), walks on walkers without resting on a damaged limb. Control radiographs were performed: standing and fixation of fragments of the left femur at the border of / 3-s / 3 is satisfactory. The stitches were removed on the 10th day, the inpatient treatment was completed, the child was discharged to the follow-up observation room of the KDO NII NDKh, full support load after 1 month, movements in full, removal of retainers after complete consolidation of the fracture after 2 months, was discharged by a healthy child.

Example 2. Patient S., 9 years, 2 months. While riding a hill, a teenager fell on her leg. We appealed to Children's hospital No.2, where a plaster cast was imposed and the girl was released for outpatient treatment at the place of residence. On the 10th day in the trauma center on the control radiographs, a displacement of the wreckage was detected and the girl was sent to hospitalization at the Scientific Research Institute of Chemical and Industrial Medicine. The girl was admitted to the department of traumatology and disaster medicine on the 10th day from the moment of the injury with the diagnosis: “A closed abnormally fractured left tibia in the middle third”. On examination, the state of moderate severity. The left lower limb is fixed by the posterior plaster cast, there are no active movements, the attempt is sharply painful, and there is no violation of innervation. After removal of the bandage, swelling of the soft tissues of the left lower leg (+2 cm on the left) was noted. After 4 hours from the moment of admission according to emergency indications, a closed reduction was performed under general anesthesia, Tenami minimally invasive metal osteosynthesis. After surgery, the difference in shin volumes decreased by 0.4 cm (+1.6 cm on the left).

On the first day after the operation, pain was noted in the damage zone, there were no active movements in the limbs, soft tissue edema persisted (+1.6 cm on the left). An ultrasound examination of the tissues of both legs showed that at the level of the middle third of the injured limb there is a cortical defect (intermittent hyperechoic cortical layer) with minimal displacement (2 mm), the layers are thickened due to soft tissue edema (+0.77 cm to the left). With identical cross-sectional dimensions of m.tibialis anterior, an increase in echogenicity, “blurring” of the structure of muscle tissue on the side of the lesion is noted. From the first day after the operation, early rehabilitation measures were started: activation and exercise therapy in bed, the first session of simulating the supporting load with the Corvit apparatus was performed. The course PION Corvit No. 8 was assigned in the “average walking” mode with a speed of 120 steps / min, the step duration is 500 milliseconds, the pressure in the pneumoestheses is 20 kPa (kilopascal), the duration is 10 minutes. On the second day, pain in the projection of the fracture decreased, movements in the knee joint: extension reached the norm - 180 degrees, flexion - 90 degrees, plantar flexion and dorsiflexion of 10 degrees in the ankle joint. On the 3rd day after the operation, after the 4th procedure with the Corvit apparatus, there was a slight pain in the fracture zone, increased movement in adjacent joints (in the knee joint: extension of 180 degrees, flexion of 110 degrees, flexion, extension in the ankle increased 10 degrees), swelling decreased (+1.5 cm on the left). The patient is upright. On day 6, the pain does not bother, the girl is active, walks on crutches without resting on a damaged limb, is fully adapted, independent, positively tuned, movements in adjacent joints in full, edema decreased (+1 cm). Ultrasound examination of the tissues of both legs at the level of the middle third of the injured limb has a cortical defect in the bone surface with a hypoechoic periosteal reaction of a linear uneven structure, the difference in soft tissues (+0.6 cm on the left). M.tibialis anterior without signs of malnutrition, increased echogenicity persists, the pattern of muscle tissue in clarity approaches the pattern of a healthy limb. On the 9th day after the operation, control radiographs show that the standing and fixation of fragments of the left tibia in the middle third is satisfactory. The stitches were removed on the 10th day, the inpatient treatment was completed, the girl was discharged to the follow-up observation room of the KDO NII NDH, full support load after 1 month, movements in full, removal of the fixators after the fracture was completely consolidated after 2 months, she was discharged by a healthy patient, the treatment was completed.

Using the method reduces pain and swelling, improves the psycho-emotional state of the child, helps to prepare the musculoskeletal and ligamentous-muscular apparatus for support, early recovery of walking, which generally eases the patient's condition.

The experience of combined use of early surgical intervention with the use of minimally invasive stable functional osteosynthesis without external immobilization and early rehabilitation using the Corvit apparatus can significantly reduce the duration of traumatic disease and the duration of rehabilitation in general.

Claims (1)

A method of early rehabilitation of children with fractures of the lower extremities, including simulating dosed muscle work, characterized in that they carry out a full-fledged simulation of the supporting load from the first day after surgery with the help of the Corvit plantar simulator of supporting load, and the child receives 8-10 procedures at a speed 120 steps / min, which corresponds to the “average walk” mode, a step duration of 500 ms and a pressure of 20 kPa in the air-pressure cutter cushion for 10 minutes.

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