RU2537780C1 - Method for surgical anatomic-functional repair of wrist joint in injured radial bone - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to traumatology and orthopaedics and can be used for the surgical anatomic-functional repair of a wrist joint in an injured radial bone. The method involves corticotomy with an osteoclasis, the radial bone distraction by transosseous osteosynthesis in an external fixation device to recover a length of the radial bone, the following osteotomy and manual reduction of the bone fragments of the distal epiphysial cartilage of the radial bone at the level of an incorrectly united fracture of the epiphysial cartilage of the radial bone. An osteotomy region is fixed with an angularly stable plate. After the distal epiphysial cartilage of the radial bone is united in a combination with removing an external plate, a tendon autograft is formed of an ulnar extensor tendon in the form of a split of no more than 40 mm long to be cut off in the proximal direction from the main tendon stem of the ulnar extensor perpendicularly to the tendon fibres. A canal is formed in the distal epiphysial cartilage of the radial bone in a saggital plane from the back surface of the radial bone to the palm (front) surface. A free end of the tendon autograft is delivered into the canal from the back to front surfaces, wound about the radial bone as a loop, and then the tendon autograft is pulled and sutured on the radial bone transosseously. A 1.5 mm pin is delivered through the distal epiphysial cartilage of both forearms with ensuring the rotational motions to be avoided for the period of at least 3 weeks.

EFFECT: method enables reducing a risk of contractures, reducing a risk of dislocation of the head of the humerus.

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Description

The present invention relates to medicine, namely to traumatology and orthopedics, can be used in the treatment of injuries of the radial bone. Indication for surgical intervention is the presence of a cosmetic defect in the patient, restriction of movements in the wrist joint and forearm joints, the presence of pain, as well as radiography, shortening of the radius and a radial angle of 0-15 ° are established.

There is a method of treating a fracture of a distal radial bone metaepiphysis fused in the wrong position (1). Osteosynthesis apparatus G.A. Ilizarov begins by holding a cantilevered transosseous element (helical shaft) through the proximal metaepiphysis at level (II, 8) at an angle of 75 ° and a cantilevered transosseous element at level (II, 9) at an angle of 90 ° to the longitudinal axis of the radius.

The proximal support based on 3/4 of the ring is oriented perpendicular to the longitudinal axis of the radius and both inserted cantilevered transosseous elements (helical rods) are fixed in the support. A cantilevered transosseous element (screw shaft) is guided through the diaphysis at the level (IV, 10) and a cantilevered transosseous element (screw shaft) at the level (VI, 10) at an angle of 90 ° to the longitudinal axis of the radius, according to the unified designation of transosseous osteosynthesis (2 , 3). Each cantilevered transosseous element is fixed in the support on the basis of 1/6 of the ring. External supports are interconnected.

After stabilization of the radius in the apparatus from an access of 15 mm, a corticotomy is performed with radius osteoclasia at the level (III) of the proximal radius of the radial bone in order to restore the length of the radius. On the 3rd day after the operation, the distillation begins discretely in time at a rate of 0.25 mm 4 times a day. The duration of distraction depends on the length of the shortening of the radius.

After the end of the distraction period, an additional cantilevered transosseous element (helical shaft) is inserted into the radial bone pineal gland and fixed to the additional sector.

At the top of the deformity in the metaphysical zone, an osteotomy is performed with simultaneous reposition under the control of an image intensifier or an x-ray machine.

Given the weight of the hand and a short distal bone fragment of the radius, to increase the stiffness of fixation, a cross of spokes is carried out through the metacarpal bones with fixation to the half-arch and the main base of the apparatus for a period of 3 weeks.

The closest is the method of surgical treatment of injuries of the radial bone developed by the authors of the proposed invention for consideration (4).

Before the operation, the optimal zones (places) of cantilever transosseous elements are determined, taking into account the features of the fracture of the distal radial bone metaepiphysis fused in the wrong position, according to the unified designation of transosseous osteosynthesis (2, 3). An external fixation device is applied to the radius. Initially, cantilevered transosseous elements, for example, screw rods, are introduced into the radius bone, for example, at pre-designated points in the proximal metaphysis, diaphysis and distal metaphysis of the radius at a right angle to the longitudinal axis of the radius in the sagittal plane:

- two in the proximal metaphysis (I, II levels),

- one in the diaphysis (IV level),

- one in the distal metaphysis (VI level).

Two rod-screws with brackets are fixed to an external support (proximal). One rod-screw with an arm to an external support (intermediate). The fourth rod-screw with the bracket to the external support (distal). External supports (1/6 ring diameter) are connected in series with threaded rods. The external fixation device is stabilized. Then, with the help of an osteotome, a corticotomy is performed with osteoclasia of the proximal radius of the metaphysis of the radius to perform distraction. On the 5th day after the operation, distraction begins, which is carried out discretely in time at 0.25 mm 4 times a day. The term of distraction of the radius in the external fixation apparatus depends on the length of the shortening of the radius and is 5-10 days to restore the original length of the radius. Then the apparatus is put into fixation mode, the period is 60-70 days until the complete reconstruction of the distraction radius bone regenerate in the corrected position.

After the end of the distraction period, an additional screw rod is inserted into the epiphysis of the radial bone, which is fixed to the additional sector of the external fixation apparatus. At the top of the deformity in the metadiaphyseal zone, an osteotomy is performed with simultaneous reposition under the control of an image intensifier or an x-ray machine. Given the weight of the hand and a short distal bone fragment of the radius, to increase the rigidity of fixation, cross needles are carried out crosswise through the metacarpal bones with fixation to the half-arch and the main base of the transosseous apparatus, the term is 3 weeks. After performing an osteotomy in the area of the distal metaphysis at the top of the deformity of the radial bone, the subsystem is placed on the wrist, movements in the wrist joint are stopped for 3 weeks.

Recovery of the patient's disability on average after 70-85 days. Movements in the elbow, wrist joints, in the proximal and distal radiolbow joints are allowed from 1 day after surgery for the entire duration of the distraction and fixation of the radius in the external fixation apparatus. Indications for the removal of the apparatus are radiological signs of fracture consolidation, as well as the lack of mobility during the clinical test. Determination of the anatomical and functional outcomes of treatment of patients with fractures of the forearm bones is performed according to the system proposed by Lyuboshits-Mattis-Schwarzberg (5, 6).

Known methods for the operative anatomical and functional restoration of the wrist joint in case of damage to the radial bone have significant disadvantages:

- The introduction of additional transosseous elements (a helical rod and two intersecting spokes), which are fixed to additional external supports, increases the dimensions of the external device.

- A helical rod inserted into the distal bone fragment of the radius, becomes unstable in a short time due to existing osteoporosis accompanying a fracture of the distal radial metaepiphysis.

- Holding two crossed knitting needles through the metacarpal bones of the hand for at least 3 weeks excludes rotational movements of the forearm, movements in the wrist joint and limits the movement of the fingers, creating 4 points of fixation of soft tissues, which contributes to the development of contractures.

- Without additional manipulations used in the proposed method, it is impossible to correct the fracture of the distal metaepiphysis of the radial bone that has grown in the wrong position and to completely restore the anatomical and functional state of the upper limb.

- The ligamentous apparatus of the distal radiolbow joint remains partially damaged, which leads to dislocation of the ulnar head (recurrent dislocation, subluxation of the ulnar head), to chronic pain syndrome, limitation of movements, post-traumatic osteoarthritis.

Based on the current level of technology for treating injuries of the radius and eliminating the disadvantages of the known methods, the task was set: to provide a more effective restoration of the anatomy and function of the upper limb, to exclude the development of contractures in the proximal and distal radiocarpal joints, wrist joint and fingers, to exclude the displacement of the head of the ulna relative to the radial bone due to the creation of the radicular ulnar ligament from its own tissues (autotendo tendon).

The task of the proposed "Method of surgical anatomical and functional restoration of the wrist joint in case of damage to the radius" is solved as follows:

Surgical restoration of the anatomical and functional state of the wrist joint in case of damage to the radius includes fixation, corticotomy with osteoclasia and distraction of the radius using transosseous osteosynthesis in an external fixation device to restore the length of the radius. Then perform osteotomy and manual reposition of bone fragments of the distal radial metaepiphysis in the correct position at the level of the fracture of the distal radial metaepiphysis fused in the wrong position. New in the proposed method is that they fix the osteotomy zone with a plate with angular stability. After fusion of the distal metaepiphysis of the radius, simultaneously with the removal of the osseous plate, tendon plastic surgery is performed. A tendon autograft is formed from the tendon of the ulnar extensor of the hand in the form of a flake no longer than 40 mm, cut off in the proximal direction from the main trunk of the tendon of the ulnar extensor of the brush perpendicular to the fibers of the tendon. Then a channel is formed in the distal metaphysis of the radius in the sagittal plane in the direction from the back (back) surface of the radius to the palmar (front) surface, the free end of the autotendinous graft is carried out in the channel from the back surface to the palmar (front). An autotendicular graft is wrapped around the ulna in the form of a loop. After that, the autotendicular graft is pulled and fixed transosseously on the radius bone. A 1.5 mm saw is carried out through the distal metaphyses of both bones of the forearm, excluding rotational movements for a period of at least 3 weeks.

We explain the significant distinguishing features of the proposed method for the surgical treatment of injuries of the radius.

Fixation of the osteotomy zone by a plate with angular stability provides a high degree of attachment of the implant to the bone, allows osteosynthesis to be less traumatic with maximum preservation of bone tissue and, in most cases, minimizes soft tissue trauma, allows early movement in joints and forearm joints to restore tone muscle and lost skills.

A plate with angular stability of the screw allows the fixator to be installed above the bone surface (epiperiostally), avoiding even the minimum pressure of the plate on the periosteum and bone skeleton during implantation. The high strength of fixation of fragments by the plate allows all screws or a significant part of them to be carried out only through one layer of compact bone (monocortical), which reduces the trauma of osteosynthesis. An important advantage of the plates with angular stability of the screw is the anatomical shape, which eliminates the need for modeling the plate, and thereby prevent secondary displacements of fragments when tightening the screws.

Performing tendon grafting after fusion of the distal radial metaepiphysis simultaneously with removal of the bone plate and forming a tendon autograft from the tendon of the ulnar extensor of the hand in the form of a flake no more than 40 mm long, cutting it off proximal to the main tendon trunk of the ulnar extensor of the hand, perpendicular to the fibers displacement of the head of the ulna relative to the ulnar notch on the radius

The formation of a channel in the distal metaphysis of the radius in the sagittal plane in the direction from the back (back) surface of the radius to the palmar (front) surface, and the free end of the autotendinous graft into this channel from the back surface to the palmar (front) is necessary for its solid growth into the intraosseous canal and tight contact of the ulnar head to the ulnar notch on the radius, which prevents the dislocation of the ulnar head.

The entwining of an autotendinous graft around the ulnar bone in the form of a loop, its tension and fixation on the radius bone with sutures transossally increases the strength of an autotendinous plastic.

A 1.5 mm knitting needle through the distal metaphyses of both forearm bones, the exclusion of rotational movements for at least 3 weeks, is necessary to create a fixation point for the formed ligament on the radius

Patent research on subclass А61В 17/56, as well as analysis of scientific and medical information reflecting the current level of technologies for treating damage to the radial bone, did not reveal identical developments. Thus, the proposed method of treatment is new.

The interconnection and interaction of the essential techniques of the proposed method ensure the achievement of a new medical result in solving the problem, namely: to restore the anatomy and function of the damaged segment of the upper limb by providing rotational movements of the forearm during the extension of the radius and excluding the development of contractures in the proximal and distal radiolactic joints, wrist joint and fingers.

The main advantages of the proposed method:

- allows you to restore the anatomy (length) of the radius and the congruence of the articular surfaces of the bones of the forearm, forming the distal radiolactic joint, by restoring the original length of the radius and soft tissue complex (autotendon tendon);

- the use of external and osseous fixators of the bone provides sufficient rigidity of osteosynthesis and stability of bone fragments, which keeps movements in the joints and joints of the forearm throughout the treatment period, preventing the development of contractures;

- allows you to achieve an increase in range of motion, including rotation, while maintaining grip and the absence of pain, to completely eliminate the cosmetic defects of the upper limb.

Thus, the proposed technical solution has an inventive step.

The proposed method for the treatment of injuries of the radial bone can be widely used in clinical practice.

"The method of surgical anatomical and functional restoration of the wrist joint in case of damage to the radius" is illustrated by illustrations, which show:

- figure 1 - scheme of fixation of the ulna with a tendon autograft to the radius:

1 - tendon autograft,

2 - tendon of the muscle of the ulnar flexor of the hand,

3 - muscle ulnar flexor of the hand,

4 - ulnar bone,

5 - radius;

- figure 2 - external fixation apparatus used in the surgical treatment of injuries of the radius;

- figure 3 is a radiograph of the left forearm of patient C. before treatment;

- figure 4 is a radiograph of the left forearm of patient C. after applying the external fixation apparatus and performing a corticotomy with osteoclasia;

- figure 5 - x-ray of the left forearm of patient C. after completion of the distraction of the radius;

- Fig.6 is a radiograph of the left forearm of patient C. after performing an osteotomy of the distal radial metaepiphysis and fixation by a plate with angular stability;

- Fig.7 is a radiograph of the left forearm of patient C. after dismantling the external fixation apparatus and fixation with a plate with angular stability;

- Fig. 8 is a radiograph of the left forearm of patient C. after treatment;

- Fig.9 - a system for determining the anatomical and functional outcomes of treatment of patients with fractures of the limbs according to Lyuboshits-Mattis-Schwarzberg.

The essence of the proposed "Method of surgical anatomical and functional restoration of the wrist joint in case of damage to the radius" is as follows:

Indication for surgical intervention is the presence of a cosmetic defect in the patient, restriction of movements in the wrist joint and forearm joints, the presence of pain, as well as radiography, shortening of the radius (congenital or acquired etiology), dislocation (subluxation) of the ulnar head, and a change in the radial angle is 0 degrees or less.

Radiography of the forearm bones is performed in two standard projections (straight and lateral) with the capture of the elbow and wrist joints.

I stage of surgical treatment

Before (the operation is prepared to complete the apparatus for transosseous osteosynthesis of the forearm bones: cantilevered transosseous elements (Shants rod conical d = 6 mm, brackets, external supports with a diameter of 1/4 of the ring, threaded rods, nuts (see the application description, figure 2) Lay the patient’s upper limb on an orthopedic attachment to the surgical table. Determine the optimal zones (places) for cantilever transosseous elements, taking into account the peculiarities of damage to the radius, according to the unified method values of transosseous osteosynthesis [2, 3]. An external fixation device is placed on the radial bone. First, console transosseous elements, for example, Schantz conical rods, are consecutively inserted into the radial bone, at the previously designated points in the proximal metaepiphysis, metaphysis and diaphysis of the radial bone at right angles to the longitudinal axis of the radius in the sagittal plane.

Two cones of Shants conical with brackets are fixed to an external support (proximal). One cone of Shants conical with a bracket is fixed to an external support (intermediate). The fourth rod of the Shchents conical with the bracket is fixed to the external support (distal). External supports (1/4 ring diameter) are connected in series with threaded rods. The external fixation device is stabilized. Then, with the help of an osteotome, a corticotomy with osteoclasia of the proximal radial bone metadiaphysis is performed to perform distraction. On the 3rd day after the operation, distraction begins, which is carried out discretely in time at 0.25 mm 4 times a day. The duration of the radius distraction in the external fixation apparatus depends on the length of the shortening of the radius to the restoration of the original length of the radius with hypercorrection of 3-4 mm. Then the apparatus is put into fixation mode; the period depends on the size of the distraction regenerate of the radial bone until it is completely rebuilt.

Movements in the elbow, wrist joints, in the proximal and distal radiolactic joints are allowed from 1 day after surgery for the entire duration of the distraction and fixation of the radius in the external fixation apparatus. The patient is observed on an outpatient basis.

II stage of surgical treatment

At the level of deformation of the fracture of the distal radial bone metaepiphysis that has grown in the wrong position, an osteotomy is performed, then the bone fragments of the radial bone are manually repositioned with the restoration of the radicular angle of at least 15 ° (normal 27 °) and the angle of inclination of the articular surface of the radial epiphysis to 10 °. Bone fragments of the radius are fixed in the corrected position with a plate with angular stability for a period of at least 8 weeks. The patient is observed on an outpatient basis.

Stage III surgical treatment

After performing a clinical test and the presence of signs of x-ray reconstruction of the distraction regenerate of the radial bone, the external fixation apparatus is removed. In the absence of x-ray signs of the reconstruction of the distraction regenerate, the external fixation apparatus is not dismantled.

Fixation of bone fragments of the distal radial metaepiphysis with a bone plate with angular stability is continued until complete fusion. After fusion of the distal radial metaepiphysis (not earlier than 8 weeks), simultaneously with the removal of the osseous plate, a tendon autograft is formed from the tendon of the ulnar extensor of the hand in the form of a flake 40 mm long at the level of the ulnar neck (see the appendix to the description of the application, Fig. 1) . The tendon autograft is cut off in the proximal direction from the main trunk of the tendon of the elbow extensor of the hand perpendicular to the tendon fibers. Then, with a drill d = 3.2 mm, a channel is formed in the distal metaphysis of the radius in the sagittal plane in the direction from the back (back) surface of the radius to the palmar (front) surface. The free end of the autotendinous graft is carried out into the formed canal from the back (back) surface to the palmar (front), twisted around the ulnar bone in the form of a loop, stretched and fixed transosseously on the radius bone. The wound is sutured in layers. Through both bones of the forearm, at the level of distal metaphyses, a d = 1.5 mm needle is passed to exclude rotational movements for 3 weeks, then the needle is removed.

Outpatient management of the patient includes rehabilitation with the use of exercise therapy to restore movements in the wrist joint in the proximal and distal radiolactic joint.

Dressings are performed once every five days or according to indications. The patient is engaged in exercise therapy with an instructor or independently, gradually increasing the load on the operated limb to full amplitude. X-ray control is performed 1 time in 4 weeks. Indications for removal of the external fixation apparatus and the osseous plate are the radiological signs of fracture consolidation, as well as the lack of mobility during the clinical test. Determination of the anatomical and functional outcomes of treatment of patients with fractures of the forearm bones is performed according to the system proposed by Lyuboshits-Mattis-Schwarzberg (5, 6). The average duration of treatment for radicular clubhand was 144 days.

The anatomy and function of the wrist joint has been restored, the damage to the radius has been repaired.

The essence of the proposed "Method of surgical anatomical and functional restoration of the wrist joint in case of damage to the radius" is illustrated by a clinical example.

Patient S., 25 years old, complained of restriction of movements in the left wrist joint and rotational movements of the left forearm, inability to fully use the left upper limb, cosmetic defects.

Anamnesis of the disease: Household injury - the hand fell under the blade of a circular saw, independently applied to the Central District Hospital of Taishet, Irkutsk Region. Diagnosis: laceration of the lower third of the left forearm. Open comminuted fracture of the distal metaepiphysis of the radius with a defect in bone tissue. Performed PHO wounds, cast gypsum splint. Immobilization for 1.5 months.

He went to the clinic of FSBI "NTSRVH" SB RAMS after 18 months from the moment of injury.

Locally: In the distal third of the left forearm, a postoperative scar in the transverse direction measuring 6.0 × 0.3 cm, pink in color, without signs of inflammation. Hypotrophy of the right upper limb. Deformation of the forearm - beam deviation. The standing of the head of the ulna on the back surface is determined, with a closed reposition, the dislocation is not eliminated. On palpation in the projection of the distal forearm, moderate soreness. Radius shortening by 10 mm. Movement in the wrist joint: flexion / extension - 15 ° / 0 ° / 25 °, radiation / elbow abduction - 15 ° / 0 ° / 20 °, movement in the joints of the forearm: supination / pronation - 65 ° / 0 ° / 0 °, movements in the elbow joint: flexion / extension - 150 ° / 0 ° / 0 °. Movement in the wrist joint is painful. Vascular, motor, sensory disorders were not detected.

Radiography of the left forearm, wrist joint was performed. Revealed: The integrity of the distal metaepiphysis of the radius has been restored, the displacement has not been eliminated, the deformation is expressed, the recurrence is 154 °. Shortening the radius to 10 mm. Radial angle 12 °. The angle of inclination of the articular surface is 10 degrees. Periosteal regenerate of medium intensity. The back dislocation of the head of the ulna is determined (see the appendix to the description of the application, Fig. 3).

Diagnosis: Fracture of the distal metaepiphysis of the left radial bone fused in the wrong position. Shortening of the left radius 10 mm. Radial oblique. An elderly back dislocation of the ulnar head. Combined contracture of the left wrist joint, rotational contracture of the joints of the left forearm.

The patient underwent surgical treatment according to the proposed method.

I stage of treatment

Four screw rods (two into the proximal metaphysis, two into the diaphysis) at a 90 ° angle to the longitudinal axis of the bone, in the sagittal plane, are successively drawn into the left radius. Each screw-rod with the help of brackets is fixed to the external supports of the apparatus in the form of a sector 1/4 of the ring. The external supports of the apparatus are connected in series with each other by threaded rods (see the appendix to the description of the application, FIG. 2). Performed a corticotomy with osteoclasia of the proximal metadiaphysis of the left radial bone using an osteotome (see the appendix to the description of the application, figure 4).

The distraction of the left radial bone started on the 5th day after the operation at a rate of 0.25 mm × 4 times a day, discretely. After restoring the original length of the left radius with hypercorrection by 4 mm, the length of the distraction regenerate is 14 mm, the external fixation apparatus was switched to fixation mode (see the appendix to the description of the application, Fig. 5). The postoperative period without complications. Movements in the elbow, wrist joints and fingers are allowed from the first day after surgery.

II stage of treatment

After lengthening the left radius, deformity correction was performed at the level of the distal radius of the radial metaphysis. Dorsal access to the distal part of the left radial bone was made. A corrective osteotomy of the distal radius of the radial bone was performed using the osteotome at the apex of deformation, bone fragments were aligned in the correct position and fixed with a bone plate with angular stability.

On the control x-ray of the left forearm and wrist joint marked: AVF of the left radial bone. The integrity of the upper third of the diaphysis of the radius is broken, a distraction regenerate of low intensity with a length of 14 mm is detected. The integrity of the distal metaepiphysis of the radius is broken, the standing of the fragments is satisfactory. Fragments are fixed by metalwork - a plate. Radio angle of 12 °. The angle of inclination of the articular surface is 10 degrees. The back dislocation of the head of the ulna remains (see the appendix to the description of the application, Fig. 6).

Movements in the elbow, wrist joints and fingers are allowed from 2 days after surgery. Discharged in satisfactory condition on the 8th day after the operation. Outpatient observation of the patient was carried out.

96 days after the operation, a clinical test was carried out and X-ray revealed that a complete reconstruction of the distraction radius bone regenerate was achieved, the external fixation device was dismantled. Distraction regenerate of uniform intensity with continuous cortical plates. Movements in the wrist joint: flexion / extension - 25 ° / 0 ° / 35 °, radiation / elbow abduction - 15 ° / 0 ° / 20 °, movements in the forearm joints: supination / pronation - 65 ° / 0 ° / 0 °, movements in the elbow joint: flexion / extension - 150 ° / 0 ° / 0 °.

Formed distraction regenerate the left radial bone (14 mm). An elderly back dislocation of the ulnar head. Combined contracture of the right wrist joint, rotational contracture of the joints of the right forearm. The external fixation device of the right forearm has been dismantled (see the appendix to the description of the application, Fig. 7). Rotational movements cause pain due to dislocation of the ulnar head.

III stage of treatment

The metalwork - an osseous plate with angular stability was removed from the distal part of the left radial bone. Elimination of the dislocation of the head of the left ulna was performed as follows: simultaneously with the removal of the osseous plate, a tendon autograft was formed from the tendon of the elbow extensor of the hand in the form of a flake 40 mm long at the level of the neck of the ulna (see the appendix to the description of the application, Fig. 1). The tendon autograft was cut off in the proximal direction from the main trunk of the tendon of the elbow extensor of the hand perpendicular to the tendon fibers. Then, with a drill d = 3.2 mm, a channel is formed in the distal metaphysis of the left radius in the sagittal plane in the direction from the back (back) surface of the radius to the palmar (front) surface. The free end of the autotendinous graft is carried out into the formed canal from the back (back) surface to the palmar (front), entwined around the ulna in the form of a loop, stretched and fixed transosseously on the radius bone. The wound is sutured in layers. A needle d = 1.5 mm was drawn through both bones of the forearm at the level of distal metaphyses to exclude rotational movements for 3 weeks, then the spoke was removed. On the 8th day I was discharged for outpatient monitoring.

On an outpatient basis, on the 21st day after the operation to eliminate the dislocation, the diafixing needle was removed, rotational movements in the joints of the forearm are allowed.

Range of motion in the wrist joint: flexion / extension - 55/00/60, abduction of the beam / elbow - 25/00/30, movements in the joints of the forearm: supination / pronation - 75/0/75, movements in the elbow joint: flexion / extension - 150/0/0. Disability is fully restored.

On the control roentgenogram of the left forearm and wrist joint, it was noted: at the level of the upper third of the diaphysis of the radius, a distraction regenerate of medium intensity with a length of 14 mm was detected. At the level of the distal metaepiphysis of the radius, the standing of the fragments is satisfactory. Radio ulnar angle of 12 °. The dorsal dislocation of the head of the ulna was eliminated.

Thus, the total period of incapacity for work was 138 days.

The anatomical and functional result of treatment according to the Mattis-Luboschitz-Schwarzberg system (5, 6) is regarded as good, the radial obliquity is corrected, the original length of the left radial bone is restored, the dislocation of the left ulnar head is corrected, the cosmetic defect is corrected, the amplitude of movements of the left upper limb is restored, The patient is satisfied with the result.

According to the proposed technology, 5 patients were treated in compliance with ethical standards and voluntary consent. No significant differences in the values of the studied parameters between the samples by age and gender were found (P> 0.05).

An analysis of the treatment results showed that the duration of treatment averaged 144.4 (139-149) days. The amplitude of movements in the elbow joint at all stages of treatment was practically unchanged and averaged 145 ° (140-150), rotational movements changed with positive dynamics at all stages of treatment. The amplitude of rotational movements in the joints of the forearm after the first stage of surgical treatment on the 2nd day after surgery was 60 ° (50-65), after completion of distraction, the average amplitude of rotational movements was 65 ° (60-75), after the second operation, the average amplitude of rotational movements 75 ° (70-85). After 3 stages of surgical correction for 3 weeks for the period of fixation with a knitting needle, there were no rotational movements, 1 month after removing the knitting needle, the amplitude of rotational movements averaged 170 ° (165-170). Soft tissue inflammation requiring conservative treatment in the area of the spokes occurred in one case - the inflammation was stopped conservatively (dressings, physiotherapy). There was no need to replace transosseous elements. These complications did not affect the duration of treatment and rehabilitation. The rehabilitation period ranged from 1 to 3 months after removal of the knitting needle, which is due to the beginning of the development of movements in the wrist joint. Three patients (60%), whose labor activity was not associated with physical activity (administrator, office manager, watchman, etc.), began to work at the stages of fixation in the device. The usual degree of social integration after 1 month occurred in 4 patients (80%), 1 patient (20%) participated in public life with slight restrictions, this is due to the presence of persistent contracture at the prehospital stage. After 6 months, all patients considered themselves socially integrated. After restoration of the anatomy of the wrist joint by the end of treatment, the function of the limb was practically in line with the functional norm.

Statistical analysis of the results was performed using the StatSoftS and Exel programs. Patients' quality of life was assessed using the DASH Questionnaire.

In addition to the study of quality of life on the questionnaires, the long-term results of treatment were evaluated by us using the Lyuboshits-Matisse-Schwarzberg system (5.6) (see the appendix to the description of the application, Fig. 9). 80% achieved a good treatment result; We have not received unsatisfactory results.

Thus, the proposed “Method for the operative anatomical and functional restoration of the wrist joint in case of damage to the radial bone” compared to the known methods for treating radial articular obstruction has improved the results of treatment of patients with this pathology by restoring the anatomy of the wrist joint, which helps to restore rotational movements in the forearm joints and movements in the wrist joint.

Sources of information taken into account

1. Ilizarov G.A., Lee A.D., Makushkin V.D. New in the treatment of acquired radial squint. // Abstract. doc. scientific-practical Conf. 50th anniversary of the formation of the USSR. - 1973. - S.163-169.

2. Solomin L.N. The basics of transosseous osteosynthesis by G.A. Ilizarova. - SPb .: MORSAR AV LLC, 2005. - 198-199 p.

3. Barabash A.P. "Esperanto" of transosseous elements during osteosynthesis by Ilizarov apparatus. / A.P. Barabash, L.N. Solomin - Novosibirsk: Science. Sib. Russian Academy of Sciences, 1997. - 188 p.

4. Puseva M.E., Mikhailov I.N., Rudakov A.N. Transosseous osteosynthesis in post-traumatic radial obliquity. // Siberian Medical Journal. - 2009. - No. 7, part 1. - S.107-110.

5. Lyuboshits N.A., Mattis E.R. Anatomical and functional assessment of treatment outcomes in patients with fractures of long tubular bones and their consequences. // Orthopedics, traumatology and prosthetics. - 1980. - No. 3. - S. 47-52.

6. Schwarzberg I.L. Methodology for assessing the long-term results of treatment of fractures of long tubular bones. // Orthopedics, traumatology and prosthetics. - 1980. - No. 3. - S. 52-55.

Claims (1)

A method for operative anatomical and functional restoration of the wrist joint in case of damage to the radius, including fixation, corticotomy with osteoclasia and distraction of the radius using transosseous osteosynthesis in an external fixation apparatus to restore the length of the radius, subsequent osteotomy and manual reposition of bone fragments of the distal bone a fracture of the distal radial bone metaepiphysis fused in the wrong position, characterized in that the zone is fixed with an osteotome and a plate with angular stability, after fusion of the distal metaepiphysis of the radius, simultaneously with the removal of the osseous plate, a tendon autograft is formed from the tendon of the ulnar extensor of the brush in the form of a flake no more than 40 mm long, cut off in the proximal direction from the main trunk of the tendon of the ulnar extensor of the brush perpendicular tendons, then form a channel in the distal metaphysis of the radius in the sagittal plane in the direction from the back (back) surface of the radius to the palm of the anterior (anterior) surface, the free end of the autotendinous graft is carried out into the canal from the dorsal surface to the anterior one, is wound around the ulnar bone in the form of a loop, after which the autotendicular graft is pulled and fixed transversely on the radius bone, after which a 1.5 mm needle is passed through the distal metaphyses of both bones of the forearm, excluding rotational movements for a period of at least 3 weeks.

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