RU2463980C1 - Method of treating severe intraarticular fractures of elbow joint - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to traumatology and orthopedics and can be used for treatment of severe intraarticular fractures of elbow joint. Skin and subcutaneous cellular tissue are dissected by cut on posterior surface of elbow joint indenting 10 cm up from ulnar process on shoulder and 6-7 cm down from ulnar process on ulnar bone crest in position of patient on back. Ulnar nerve is exposed along 3-4 cm and taken on rubber holder. On shoulder superficial fascia is dissected and medial head of triceps is split along fibres up to shoulder bone bluntly. Tendon of triceps is dissected longitudinally distally on 1.5-2 cm. Depending on specific anatomical situation ulnar process, condyles of humerus and other large fragments and splinters are exposed and removed subperiostally or osteotomy of ulnar process on 0.5 cm is performed; elbow joint is opened, fragments and splinters are removed, transversal, T or L-shaped osteotomy is performed. Installation of endoprosthesis components is carried out.

EFFECT: method ensures simultaneous restoration of structure and function of elbow joint, reduction of post-operative complications.

4 cl, 1 ex, 4 dwg

Description

Severe intraarticular fractures of the elbow joint (type C 2-3), leading to serious consequences, are quite common and make up 5.5-9.7% of all fractures of the limb bones (1, 5, 14). This is due, first of all, to the topographic, anatomical and functional features of the elbow joint, which consists of three rather independent and at the same time closely interconnected joints (shoulder-elbow, brachioradial and ray-elbow). In addition, the elbow joint has specific features of biomechanics, blood supply and innervation (7, 13). It is known that even a minor injury to the elbow joint, without bone fractures, congruence of the articular surfaces, damage to the musculo-ligamentous apparatus, can lead to serious complications, such as ossification of the joint, contractures of varying severity, ankylosis (3, 6, 9, 10).

Numerous conservative methods of treating severe injuries of the elbow joint are often ineffective, and sometimes lead to the opposite effect (4, 11, 12). Osteosynthesis of fractures of the bones forming the ulnar joint, regardless of its method and structures used, especially for complex fractures of type C 2-3, as well as for chronic injuries, often leads to the formation of non-healing fractures, false joints, contractures and ankylosis of the joints, neurogenic complications ( 2, 8).

In this regard, the search for alternative, non-traditional approaches in the treatment of patients with severe injuries of the elbow joint is very relevant.

The invention relates to medicine, namely to traumatology and orthopedics, and consists in the development of a new method for the treatment of severe intraarticular fractures of the elbow joint.

A known method of treating severe fractures of the elbow joint of type C2-3, providing for the osteosynthesis of fractures of the elbow joint of C2-3 type with submersible structures (plates, screws, knitting needles), including submersible structures of the AO system with subsequent limb immobilization with plaster dressings for 6-12 days or more (Kallaev N.O., Kallaev T.N., Omarov M.M., Shapiev M.A. Comparative results of surgical treatment of near- and intraarticular fractures of the distal humerus // in the materials of the International Pirogov scientific-practical conference "Osteosynthesis and endoprosthetics" on May 15-16, 2008, Moscow, p. 8). The method is effective, applied to a large number of patients (142 patients). However, when assessing the results of treatment after 1-8 years, it was found that only 77.6% of patients received positive treatment results, deep suppuration of soft tissues with the development of osteomyelitis (2) and arthritis (1) were observed in 3 (3.1%) patients. , in 6 (6.1%) contractures, deforming arthrosis was detected in 8 (8.2%), and paraarticular ossificates in 5 (5.1%). Thus, the total number of complications in patients treated with this method occurred in 22.5% of cases.

Materials and methods. Under our supervision, there were 49 patients with fractures of type 2, 3 bone bones that underwent total elbow joint replacement surgery. The age of patients from 26 years to 71 years. 29 men were treated, 20 women.

Preoperative examination included standard radiography in 2 projections, CT of the elbow joints, and, if necessary, electroneuromyography. Clinical, laboratory and instrumental research was carried out in a standard volume for operations of this level and degree of complexity.

For the operation of total arthroplasty of the elbow joint, we used implants of the ESI firm (Russia) (Fig. 1), as well as sets of special tools of this firm (Fig. 2).

The endoprosthesis of Endoservice is of a connected type and consists of 4 sizes (1, 2, 3, 4), shoulder and elbow components, combined with each other. The shoulder component is individual for the right and left sides. Fixation of the components of the endoprosthesis is cement. The humeral and ulnar legs of the endoprosthesis are connected using a special hinge device and are blocked by a screw lock. The design of endoprosthesis ESI allows you to restore almost the full amount of flexion and extension in the elbow joint (180-40-50 °) and rotational movements up to 10-15 °.

Operation technique (Fig. 3, explanations in the text). The optimal position of the patient on the table is on the stomach with the arm laid on the side table and the roller under the elbow joint. However, the position of the patient on his back with his arm lying freely on the chest is also quite convenient (1). Anesthesia - ETN. A hemostatic tourniquet is applied at the border of the middle and upper third of the shoulder. A cut along the posterior surface of the elbow joint, backing 10 cm up from the ulnar process on the shoulder and up to 6-7 cm down from the ulnar process along the crest of the ulnar bone, cuts the skin, subcutaneous tissue. In the groove between the ulnar process and the internal condyle of the humerus, the ulnar nerve is secreted for 3-4 cm and is taken on a rubber holder (2). The superficial fascia is dissected on the shoulder and the medial head of the triceps muscle bluntly stratifies along the fibers, up to the humerus, the tendon of the triceps muscle, which is attached to the ulnar process, is dissected longitudinally by 1.5-2 cm distally (3). The ulnar process of the ulna, the condyles of the humerus or large fragments and fragments of the subperiosteal are secreted. An osteotomy of the ulnar process is 0.5 cm (4), after which the ulnar joint is opened (5). A transverse osteotomy was performed with the removal of fragments and fragments, T- or L-shaped in other cases (6), depending on the specific anatomical situation. With significant destruction of the radial head, which is often observed with severe traumatic injuries, the head was resected and replaced by an endoprosthesis of the radial head (7). The bone marrow channels of the humerus and ulna were opened and developed to the required size (8). The fitting patterns of the shoulder and elbow components were installed, which were connected by a temporary fixative, and the volume and freedom of movement in the joint were determined. Permanent components of the endoprosthesis were installed on cement (9) and fixed in the articulated mechanism with a special clamp (10). The volume and freedom of movement in the joint were checked once again (11, 12). A separate bed was formed for the ulnar nerve, in which it was sutured. This was done in order to exclude the contact of the ulnar nerve with bone or metal structures.

The wound was sutured in layers and actively drained for 1 day.

In the postoperative period, the elbow joint was fixed with a soft bandage at an angle of 90 ° for 3-5 days. (until the swelling subsides), then dosed movements in the joint are started, bringing them to full volume by the end of 2-3 weeks. The patients were prescribed physical therapy, massage of the muscles of the shoulder, forearm, hand, and after removing the sutures - hydromassage and exercises in the swimming pool.

The results of the study.

Clinical x-ray examination of 45 patients in the period from 1 year to 4 years after surgery was subjected to analysis. The analyzed group included 23 men and 18 women. Evaluation of the results was carried out on the "Assessment of elbow surgery" (American elbow surgeons assessment & ASES, Richards R.R. et al. 1994). The test allows you to evaluate the severity of pain, the amplitude of movements in the elbow joint, the condition of the joint, arm strength and daily life activity. The maximum number of points (100) on this scale corresponds to the normal condition of the elbow joint. Good and excellent results when assessed 1-4 years after surgery (more than 70 points) were obtained in 41 patients, which amounted to 91.1% of all treated; satisfactory results (50-69 points) were recorded in 2 patients, respectively 4.4% of all treated. An unsatisfactory endoprosthetics result was observed in 2 patients (4.4% of the total number of operated), was associated with the development of deep suppuration of the endoprosthesis area in these patients after 5 and 11 months. after an operation that was stopped only after removal of the structure.

Clinical example. Patient N. 71 years. Was admitted to the orthopedic department of the Design Bureau of the city of Saratov on 08/06/2007. Diagnosis: closed fragmentary-comminuted intercondylar fracture of the left humerus with displacement of fragments (C3) (figure 4).

08/08/2007 operation - total endoprosthetics of the left elbow joint with an ESI endoprosthesis. The postoperative period was uneventful. A satisfactory range of motion in the joint was achieved 7 days after surgery. Observation of the patient 3.5 years. The range of motion is good, the patient is pleased with the results of the operation.

Thus, total endoprosthetics allows to restore the function of the elbow joint and upper limb as a whole with severe fragmentary-comminuted intraarticular fractures of the bones that make up the ulnar joint (type C2, type 3), which are “unpromising” for osteosynthesis, especially in the elderly.

Claims (4)

1. A method for the treatment of severe intraarticular fractures of the elbow joint, including endoprosthetics of the elbow joint, characterized in that in the position of the patient on the back with an incision along the posterior surface of the elbow joint, backing 10 cm up from the ulnar process on the shoulder and 6-7 cm down from the ulnar process the crest of the ulnar bone, dissect the skin, subcutaneous tissue, secrete the ulnar nerve for 3-4 cm and take it on a rubber holder, on the shoulder dissect the superficial fascia and stupidly delaminate along the fibers the medial head of the trigger howling muscle down to the humerus, the tendon of the triceps muscle is dissected longitudinally distally by 1.5-2 cm, depending on the specific anatomical situation, the ulnar process, the condyles of the humerus and other large fragments and fragments of the subperiosteum secrete and remove or produce an osteotomy of the ulnar process by 0 5 cm; open the elbow joint, remove fragments and fragments, produce a transverse, T or G shaped osteotomy. 2. The method according to claim 1, characterized in that with significant destruction of the radial head, it is resected and replaced by an endoprosthesis of the radial head. 3. The method according to claim 1, characterized in that the bone marrow channels of the humerus and ulna are opened and developed to the required size; fitting patterns of the shoulder and elbow components are installed, which are connected by a temporary latch; determined by the volume and freedom of movement in the joint. 4. The method according to claim 1, characterized in that permanent components of the endoprosthesis are installed on the bone cement and fixed in the articulated mechanism with a special clamp, after which the volume and freedom of movement in the joint are checked again; for the ulnar nerve, a separate bed is formed in which it is sutured; the wound is sutured in layers and actively drained for 1 day.

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