RU2460487C1 - Method of finger formation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to reconstructive surgery. Filatov Gillies tubed pedicle is transplanted on stump of first and second metacarpal bones with formation of loop. After engraftment of tubed pedicle feeding pedicle is formed including in it skin-fatty tape on palm surface, palm inter-metacarpus arteries and common finger nerves. Tendon of first back interosseous muscle is cut off from place of attachment. Longitudinal bone fragment is transferred from second metacarpus on palm feeding pedicle on first metacarpus stump. Tendon of first back inbterosseous muscle is sutured to preserved fragment of second metacarpus. Plasty of first interdigital space is performed by means of formed triangular skin flap. Skin-fatty tape is placed on elbow surface of restored finger. Loop from Filatov Gillies tubed pedicle is cut across and formed halves are used to replace defects of soft tissues in area of second metacarpus and restored first finger.

EFFECT: method ensures adequate blood supply of replaced fragment, restoration of adequate hand skin and sensitivity of formed finger.

1 ex, 3 dwg

Description

The present invention relates to medicine, namely to reconstructive hand surgery.

Known methods of forming a finger of the hand, for example, the Littler method (Littler JW The neurovascular pedicle method of digital transposition for reconstruction of the thumb // Plast. Reconstr. Surg. - 1953. - V.12. - P.303-319), which consists in the formation of the feeding leg, including the neurovascular bundles and the movement of a full-volume segment on it.

However, moving a stump of a finger with a fragment of the metacarpal bone or stump of the metacarpal bone can lead to a narrowing of the hand and a decrease in its functionality.

There is also a method of forming a finger of a brush described by W. Blauth (Blauth W. Der hypoplastische Daumen // Arch. Orthop. Unfall-Chir. - 1967. - Bd.62, p. - 225-246), by moving a longitudinal bone graft from the second metacarpal bone on the feeding leg, consisting of the metacarpal arteries, in the position of the first metacarpal bone.

However, the method has disadvantages: 1) the feeding leg is of insufficient length, and therefore the method allows you to connect the fragment only with the bones of the wrist and does not allow you to move the fragment to the stump of the first metacarpal bone; 2) the method does not provide mobility in the first carpal-metacarpal joint of the restored finger; 3) the use of free skin grafts does not allow the formation of adequate skin of the finger and the first interdigital gap; 4) the method does not eliminate the narrowing of the hand, since the osteotomy of the second metacarpal bone is performed in the sagittal plane and the width of the palm is reduced by half the diameter of the metacarpal bone; 5) the first interdigital gap is formed in an inadequate form.

Closest to the proposed method is a method of forming a finger of the hand, which consists in moving a longitudinal fragment of the second metacarpal bone, which is included in the back and palmar flaps of a tongue-like shape, on the stump of the first metacarpal bone and forming due to these flaps of soft tissues of the finger (A.S. No. 1118354, 1984).

However, the known method has the following disadvantages: 1) there is a need for transplantation of free skin grafts on the back and palmar surfaces of the hand, which is undesirable, since the grafts are prone to scarring and ulceration under load; 2) axial vessels are not included in the flaps; therefore, blood supply to the bone fragment is carried out only by the muscle vessels and is insufficient; 3) the sensitivity of the restored finger is insufficient, since the skin flaps lack sensitive skin nerves (finger nerves); 4) there is a high probability of the formation of the leading contracture of the first metacarpal bone, since when the method is implemented, a linear skin scar is inevitably formed located in the region of the bottom of the first interdigital gap.

The task of the invention is to improve the method.

EFFECT: provision of adequate blood supply to the displaced fragment, restoration of full integument of the hand and sensitivity of the formed finger.

The technical result is achieved due to the fact that in a method involving the movement of a longitudinal bone graft from the second metacarpal bone on the feeding leg, the Filatov stem is transplanted onto the stump of the first and second metacarpal bone to form a loop, after the engraftment of the stem, the feeding leg is formed with the cutaneous adipose tape along the palmar surface, the palmar intercarpal arteries and the general digital nerves, cut the tendon of the first dorsal interosseous muscle from the place of attachment, transfer a longitudinal fragment to the palmar to the stump of the first metacarpal bone, the tendon of the first dorsal interosseous muscle is sutured to the preserved fragment of the second metacarpal bone, the first interdigital gap is plasticized by the formed triangular skin flap, the skin-fatty tape is placed on the ulnar surface of the restored finger, and the loop from the Filat stem is crossed the resulting halves replace defects in soft tissues in the region of the second metacarpal bone and the restored first finger.

The essence of the formation of the finger of the brush is illustrated by drawings, where Fig. 1 shows the stalk of Filatov transplanted onto the stump of the brush with the formation of a loop; figure 2 is a longitudinal fragment of the second metacarpal bone mobilized on the palmar feeding leg; figure 3 is a longitudinal fragment of the second metacarpal bone, moved on the feeding leg to the stump of the first metacarpal bone with the replacement of soft tissue defects on the restored first finger and in the region of the second metacarpal bone with a Filatov stalk.

The method is as follows.

Preliminarily form the stalk of 1 Filatov on the stomach. Next, perform the migration of the stem to the brush with the formation of a loop, while one end of the stem 1 is sutured to the cult of the first finger, and the second to the cult of the second metacarpal bone (Figure 1, 2). Two months later, the actual formation of the finger is performed.

On the palmar surface of the hand, two parallel linear cuts are performed at a distance of 1.5-2 cm from each other in the projection of the second metacarpal bone parallel to its longitudinal axis without separating the resulting skin-fatty tape from the underlying tissues, which completely covers the tendons, palmar metacarpal arteries and common finger nerves, as well as the metacarpal bone. Neurovascular bundles are mobilized without breaking their connections with the resulting skin-fatty tape, tendons and metacarpal bone. In the distal section, the skin bridge is crossed at the border of the flap from the stem 1, stitched to the end of the stump of the second metacarpal bone. The tendon part of the first dorsal interosseous muscle and partially transverse head of the adductor muscle are cut off from the second metacarpal bone. A longitudinal osteotomy of the second metacarpal bone is performed in the frontal plane, making an incision from the distal stump to the proximal third of the bone using an oscillatory saw, without breaking the connection between the formed palmar half of the second metacarpal bone and the palmar feeding leg. At the level of the proximal end of the cut, a transverse osteotomy of the formed palmar half of the metacarpal bone is performed, as a result of which a longitudinal palmar fragment 2 of the second metacarpal bone is formed, connected with the palmar feeding leg 3, including the skin-fatty tape, flexor tendons and neurovascular bundles (Figure 2 ) The incision in the palm is extended from the lateral edge of the proximal part of the feeding leg in the projection of the first metacarpal bone to its end, as a result of which a triangular skin flap 4 is formed in the first interdigital gap with the base on the back of the hand (Figure 3). The skin flap 4 is separated in the proximal direction, the edges of the wound are mobilized in the region of the first metacarpal bone. The butt of the stump of the first metacarpal bone is exposed. Drill its marrow canal with cylindrical cutters. The palm fragment 2 of the second metacarpal bone is transferred to the stump of the first metacarpal bone on the palmar feeding leg 3 (Figure 3). The leg is placed in the formed bed in the region of the first metacarpal bone. Osteosynthesis of bone fragments is performed by implantation with additional fixation with a spoke. The first dorsal interosseous muscle and the transverse head of the adducting first finger muscles are fixed to the preserved fragment of the second metacarpal bone with transossal sutures. A triangular skin flap 4 is laid on the bottom of the formed first interdigital gap. The skin tape of the feeding leg 3 is laid on the ulnar surface of the restored finger. The loop from the stem of 1 Filatov is crossed and divided into two equal parts. Dissect along the scar, unfold and spread the formed halves of the stem 1 on the stumps of the first and second metacarpal bones. The resulting skin defects along the radial, dorsum of the first finger and the palmar-radial surface of the second metacarpal bone are closed with stalked flaps (Figure 3). The hand and forearm are fixed with a plaster cast for 1 month.

Clinical example.

B-B-in E.A., 41 years old, and.b. 245624, was treated at the Nizhny Novgorod Research Institute of Traumatology and Orthopedics in June 2009 for a stump of the first finger at the middle third of the main phalanx, a stump of the third finger at the base of the main phalanx, stumps of 2, 4, 5 metacarpal bones at the level of the heads on the right brushes, stumps of 1-5 metacarpal bones of the left hand at the level of the heads. From the anamnesis of the disease, it is known that the patient received frostbite of his hands in 2006, about which finger necrectomy was performed. As a result of the injury, the patient almost completely lost the possibility of self-care, using for this purpose only the stump of the first finger of the right hand. The functionality of the left hand is completely absent, in connection with which it was decided to restore the first finger in order to ensure a bilateral grip. The first stage was plastic surgery of the stump of the hand with a sharp Filatov stalk formed on the stomach (06/09/09). In this case, the stem was hemmed in the region of the butt end of the second metacarpal bone. After engraftment of this end of the stem, its second end was hemmed to the end of the stump of the first metacarpal bone (06/30/09). The longitudinal fragment of the second metacarpal bone on the palmar skin-vascular pedicle was moved to the stump of the first metacarpal bone according to the developed method on 2.02.10 g. Soft tissue defects formed on the palmar-radial surface of the second metacarpal bone and the dorso-radial surface of the formed first finger were replaced by flaps formed after separation into two parts of the loop from the stalk of Filatov. At the same time, with the help of the skin portion of the feeding leg, the palm-elbow surface of the first finger was formed. The first interdigital gap was formed due to the back skin-fat flap of a triangular shape, formed during the formation of the feeding leg and the movement of the segment of the metacarpal bone on it. The postoperative period was uneventful, the wounds healed by first intention, the stalked and triangular flaps completely healed. Subsequently, the correction of the excess parts of the stalked flaps was performed (09/14/10). When studying the long-term results of treatment (02/09/11), it was noted that the length of the first ray is 7 cm, the depth of the first interdigital gap is 4 cm. Movements in the wrist-metacarpal joint of the first finger are fully possible. With the maximum abduction of the first ray, the distance between its end part and the similar anatomical landmark of the preserved part of the second metacarpal bone is 6 cm, and the reduction of the first ray to the second is complete. Discrimination sensitivity on the working surface of the finger is 5 mm. Stalked flaps without any signs of trophic disorders. The formed first finger allows you to hold objects of various sizes and shapes with a brush. Using the preserved functional capabilities of the stump of the right hand and the restored function of the grip of the left hand, the patient not only serves himself, but also performs socially useful work. On radiographs of the brush, the preserved and displaced parts of the second metacarpal bone have the usual structure, with no signs of resorption.

Thus, the developed method allows you to move a longitudinal fragment of the second metacarpal bone on the stump of the first metacarpal bone at the level of the head of the first metacarpal bone and restore the first finger of the required size.

The inclusion in the composition of the feeding leg of the palmar metacarpal arteries, and accordingly the vessels departing from them, supplying the longitudinal fragment of the second metacarpal bone, increases the mobility of the transported fragment and ensures its adequate blood supply.

The presence in the composition of the feeding leg and common finger nerves innervating the skin tape covering the neurovascular bundles allows the working surface of the restored first finger to be formed with adequate sensitivity.

Performing an osteotomy of the second metacarpal bone in the frontal plane ensures the preservation of the width of the palm, the stability of the grip of the hand and the improvement of its strength indicators.

When implementing the method, the first interdigital gap is formed of an adequate shape, which allows you to reliably hold objects.

Claims (1)

A method of forming a finger of a brush by moving a longitudinal bone graft from the second metacarpal bone on the feeding leg, characterized in that the Filatov stalk is transplanted onto the stump of the first and second metacarpal bones to form a loop, after the stem has been engrafted, a feeding leg is formed with the inclusion of skin-fatty tape along of the palmar surface, palmar intercarpal arteries and common finger nerves, the tendon of the first dorsal interosseous muscle is cut off from the attachment point, a longitudinal fragment is transferred to the palmar feeding knife e on the stump of the first metacarpal bone, the tendon of the first dorsal interosseous muscle is sutured to the preserved fragment of the second metacarpal bone, plastic surgery of the first interdigital gap is performed due to the formed triangular skin flap, a skin-fatty tape is placed on the ulnar surface of the restored finger, and the loop from the stem of Filatov is crossed and formed halves replace defects in soft tissues in the region of the second metacarpal bone and the restored first finger.

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