RU2564080C1 - Method for temporal fixation of intra-articular fractures of distal shin bones - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: wires are inserted through the middle of a calcaneal bone from outside to inside at an angle of 10-15° to a frontal plane of an ankle joint. The wires are delivered at the level of a tibial tuberosity perpendicularly to a sagittal axis of a tibia. The shin bone is positioned in a frame supported by an external fixation apparatus and assembled of a proximal end and a distal segment as a three-quarter circle; the latter are connected together by telescopic rods; the two rods are installed along an external and internal surface with respect to the shin; one rod is arranged along a posterior external surface of the shin. The wire delivered through the calcaneal bone is fixed. That is followed by manual reposition to eliminate rotation displacement at the level of the fracture by aligning one interdigital space along a line: an anterior superior iliac spine and an internal edge of a patella. Once the rotation displacements at the level of the fracture are eliminated, the wire delivered through a tibial metaphysis is fixed. Distraction follows until axial interrelations of the tibial and fibular fragments and a uniformity of a joint space of the ankle are restored. Once the fragments achieve their biochemically correct position, additional wires are inserted through a proximal metaphysis of the tibia and the calcaneal bone, at an angle of those delivered before.

EFFECT: method enables reducing time of apparatus application.

2 cl, 6 dwg

Description

The invention relates to medicine, namely to traumatology and orthopedics, in particular to methods of preoperative preparation using an external fixation apparatus in the treatment of leg fractures.

Most patients with complex intraarticular injuries of the distal metaepiphysis of the tibia receive specialized treatment in the trauma departments of city and district hospitals. Most often, when a patient enters the admission department, the fixation of the damaged limb is carried out using skeletal traction over the calcaneus.

There is a method of treating intraarticular fractures of the distal leg, which consists in the use of a temporary combination of constant skeletal traction with submersible structures: a plate and screws. In this case, the fibula is repaired and fixed simultaneously with the tibia from one surgical approach. Use the same designs. The screws are introduced from the inside outward at an angle of 30 ° to the frontal plane (Patent No. 2442546, RU. Publish. 02.20.2012).

However, in the known method, the use of permanent skeletal traction, as the first stage of preoperative preparation, does not allow for adequate ligamentotaxis, since traction goes only through the calcaneus, in the preoperative period reduces the patient's quality of life (bed rest, inability to self-service, poor personal hygiene), and indirect fixation of the fibula increases the risk of deformities at the fracture level.

Known is a combined method of reposition and fixation of fractures of the lower leg bones in a plaster cast, in which two spokes with a bayonet-shaped bend are carried through the upper and lower metaepiphyses of the tibia, a gypsum dressing is applied. After the dressing has hardened, windows are cut out in the area of the knitting needles, staples are applied to tighten the needles, then reposition is performed by applying a reponing force to the end of the longer bone fragment fixed in the brace to the distal tibia meta-epiphysis through the stop with the brace into the plaster cast. Stabilization of a long bone fragment of the damaged segment is carried out by three combined fixation sites not lying on the same straight line (Patent No. 2187977 RU. Publish. 08.27.2002).

However, the disadvantages of this method are the need to conduct the needle through the distal metaphysis of the tibia, which is technically not feasible with comminuted intraarticular fractures of the distal parts of the lower leg bones. In addition, the fixation of a fracture of the distal part of the lower leg bones, in a plaster cast, does not allow adequate control over the state of soft tissues at the level of the distal lower leg.

A known method of treating intraarticular fractures of the distal leg bones according to G.A. Ilizarova, in which osteosynthesis of the lower leg bones begins with the installation of a module based on two supports: the proximal base and repositional-fixation (AVF). An annular support is fixed to the indicated module at level VIII of the lower leg. Next, mount the support on the foot. They grab the support with their hands, attempt an enclosed manual reposition of the fragments, after which the distal support is connected with 3-4 rods to the base apparatus and a distraction force is applied. Perform x-ray control. Next, a knitting needle VI, 3-9 is carried out at the level of the repositional-fixation ring of the lower leg, which allows the correction of the position of the proximal fragment and its stabilization. In the case of ineffective ligamentotaxis, they go to the stage of open reposition, when restoration of congruency of the articular surface, additional transosseous elements (knitting needles, cantilever spokes) are carried out taking into account the location of the fragments (Solomin L.N. Fundamentals of transosseous osteosynthesis with the apparatus of G.A. Ilizarov: Monograph .-- St. Petersburg LLC “MORSAR AV”, 2005. - 544 p.).

However, the surgical intervention in a known manner is long enough, which excludes the use of this AVF in the admission department, holding the spokes through the fragments of the fracture increases the risk of spoke-associated infectious complications.

A known method of cortical combined osteosynthesis, which allows to reduce the number of transdermally performed elements in the ankle joint, including the use of AVF (ring at the level of the middle third of the lower leg - half ring at the level of the calcaneus, fixed on the knitting needles) + screw fixation of fragments using a special trocar. When implementing this method of cortical combined osteosynthesis, a closed reposition is performed in the AVF according to Ilizarov, fixation of large bone fragments with screws, then removal of the AVF 3-6 weeks after stopping early post-traumatic changes in the injury area (after 3-6 weeks) with the development of movements in the ankle joint (Abramov I.V. Minimally invasive combined osteosynthesis in the treatment of complex fractures of the distal bones of the lower leg, diss. Candidate of medical sciences Moscow. - 2008. - P. 39).

However, the known method uses a rather bulky design, additional x-ray control is required, secondary displacement of fragments, closed reposition, AVF and fixation of fragments by screws are unacceptable for comminuted fractures, when high demands are made on congruency of the articular surface, in addition, the use of this technology is only possible in a planned operating environment.

The known technique of closed hardware intraoperative reposition (ZAIR) of the posterior edge of the tibia using a reponition device, in case of significant swelling of soft tissues. The Achilles tendon is shifted medially by finger pressure, through the puncture of the skin, the reponent element 1 is inserted all the way into the fragment of the posterior edge. After that, the clutch 2 is fixed in the bracket by rotation of the bolt 3. Then, the reponent element 1 is rotated until the end of it having the corkscrew cut is inserted into the fragment 11. The penetration depth is determined radiologically. Then the bolt 3 is loosened, by pulling over the end of the reponent element 1, fragment 11 is displaced posteriorly by the size of the largest protrusion along the fracture line, after which the clutch 2 with the reponent element 1 is again fixed in the bracket 4. By rotating the nuts 7, the bracket is shifted down to accommodate the fracture lines of fragment 11 and tibia 8 at the same level, as evidenced by a control radiograph. Then the bolt 3 is loosened, the reponent element 1 is shifted anteriorly until the fragment 11 rests in the tibia 8. After that, the fragment 11 is fixed with transversely threaded knitting needles to the tibia. The reponent element 1 and the outer supports 6 together with the spokes 10 are removed. After squeezing the soft tissues, the threaded knitting needles are bitten with nippers and immersed under the skin. A gypsum splint is applied for 10-12 days until the edema subsides (Chermakov K.S. Minimally invasive osteosynthesis of posterior marginal fractures of the distal tibia pineal gland (clinical and experimental study) // Diss. Ph.D. Cheboksary.- 2010. - С . fifty).

However, in the known method a closed reposition of only one fragment (the posterior edge of the tibia) is carried out, which with comminuted fractures of the tibia cannot solve the problem of reposition of all fragments, there is a need for special tools, multiple x-ray control, and fixation of bone fragments cannot provide sufficient stability, which requires additional fixation of the limb with a plaster cast.

There is a method of treating comminuted intraarticular fractures of the distal leg bones with a significant displacement, which consists in maintaining the proximal bolt of the femoral distractor at a right angle to the axis of the tibia above the fracture level, the distal bolt of the femoral distractor is inserted in the frontal plane into the talus parallel to its articular surface, the distraction is carried out along the axis (Mast J, Jakob R, Ganz R: Planning and reduction technique in fracture surgery, Berlin, 1989, Springer-Verlag; Campbell - part XV - chapter 51).

However, the disadvantages of the known method are the use of a femoral distractor immediately before stabilization of the fracture by submersible metal structures, which excludes its use at the stage of emergency rest, and technically difficult reposition of screws inserted in the same plane into the bone tissue.

There is a method of closed reposition of pylon fractures with fixation by an external fixation apparatus. Through the calcaneus, taking into account the valgus-varus displacement of the fragments, a spoke is drawn, then two crossed knitting needles are held in the upper third of the lower leg at an angle, the limb is placed on a special splint to reposition the lower leg. The tire consists of three arcs of the Ilizarov apparatus, fastened together, with two slots (the distal part). One arc is turned up and goes in a groove between the last two. On the other hand, two arcs are fixed together by screws together (proximal part). The structures of the arcs are interconnected by four long telescopic rods with the possibility of longitudinal movement, allowing you to adjust the length of the leg. In the distal part of the structure, a straight plate with holes is blocking the upper arc, to which a distraction rod with a bracket is attached. To the proximal part of the repositional tire, spokes fixed in the upper third of the tibia are fastened with special fixators, and in the distal part of the tire, the needle is drawn through the calcaneus, which is attached to the semicircle. After tensioning the spokes in this tire, it is possible to eliminate coarse displacements by traction along the longitudinal axis, then rotational and angular. Perform control radiographs. The method is positioned as preparation of a limb for final fixation of a segment in an external fixation apparatus according to Ilizarov (with or without internal metal fixators) (Dryagin V.G., Lazarev A.F. Clinical lectures on traumatology (fractures of the pylon and ankles) / Chelyabinsk. - 2007. - 80 p.).

However, in the known method, a rather complex massive system of the repair tire was used, which does not imply the patient’s activation in the immediate period after the injury, moreover, this method is not intended to optimize the two-stage tactics of managing patients with preparing the skin of the lower leg for final osteosynthesis.

The objective of the invention is to optimize a two-stage tactics of managing patients with intraarticular fractures of the distal leg bones by minimally invasive closed reposition of the fracture in the AVF, the solution of which is manifested in a reduction in the application time of the apparatus and subsequent adequate preparation of the skin of the leg and foot for the final osteosynthesis without fixing fragments fibula.

The problem is achieved in a method of temporary fixation of intraarticular fractures of the distal part of the lower leg bones, including conducting crossed knitting needles through the tibia and heel bone, fixing the knitting needles in the proximal and distal supports of the external fixation apparatus (AVF), holding the knitting needles through the middle of the calcaneus from the outside inward at an angle of 10 15 ° to the frontal plane of the ankle joint, then the needles are held at the level of the tibial tuberosity perpendicular to the sagittal axis of the tibia, e of this shin is placed in the AVF frame, which is assembled from the proximal ring and the distal sector as a% ring, the latter are connected together by telescopic rods, while two rods are installed on the outer and inner surfaces relative to the lower leg, one rod is placed on the back-outer the surface of the lower leg, fix the knitting needle through the calcaneus, carry out a closed manual reposition, eliminating rotational displacement at the fracture level, by centering one interdigital space of the foot along lines: the anterior superior iliac spine - the inner edge of the patella, eliminating rotational displacements at the fracture level, fix the knitting needle through the metaphysis of the tibia, then distract until the axial relationship of the fragments of the tibia and fibula and uniformity of the joint space of the ankle, ankle joint upon reaching the biomechanically correct position of the fragments, additional knitting needles are passed through the proximal metaphysis of the tibia and calcaneus, at an angle to the previous ones, a phased x-ray control is carried out.

It is advisable to use knitting needles with a diameter of not more than two millimeters, which creates the most optimal conditions for fixing the bone without increasing its trauma.

The present invention is illustrated by a detailed description and copies of x-rays, in which:

FIG. 1 is a radiograph of patient I. upon admission to the receiving department in a lateral projection, which depicts a fracture of the distal part of the left tibia, the lower third of the diaphysis of the fibula;

FIG. 2 - a radiograph of patient I. upon admission to the receiving department in a direct projection, which shows a fracture of the distal part of the left tibia, the lower third of the diaphysis of the fibula;

FIG. 3 - the photo shows a side view when fixing a bone fracture of the left lower leg with distraction AVF;

FIG. 4 - the photo illustrates the anterior surface of the lower leg during fixation of the fracture in AVF after distraction;

FIG. 5 is a control x-ray of the left ankle joint under conditions of distraction AVF (lateral projection), which shows the elimination of gross displacements of fragments of b / b and m / b bones with restoration of the limb axis in the sagittal plane, the joint gap is uniform;

FIG. 6 - control x-ray of the left ankle under conditions of distraction AVF (anteroposterior projection), which shows the elimination of gross displacements of fragments of b / b and m / b bones with the restoration of the axis of the limb in the sagittal plane, the joint space is uniform.

The method of temporary fixation of fractures of the distal bones of the leg is as follows.

It is a well-known fact that there is a direct relationship between the time of reposition during intraarticular fractures of the distal leg and the risk of trophoneurotic disorders in the distal region of the leg and ankle.

The method of temporary fixation of intraarticular fractures of the distal shin bones (plafond fractures) involves carrying out crossed knitting needles through the tibia and calcaneus, fixing the knitting needles in the proximal and distal supports of the external fixation apparatus (AVF).

The position of the patient on the back. Anesthesia is performed using endotracheal anesthesia, or spinal anesthesia, or local anesthesia. Through the middle of the calcaneus from the outside inward at an angle of 10-15 degrees to the frontal plane of the ankle joint, a 2 mm spoke. Then a 2 mm spoke is held at the tibial tuberosity level perpendicular to the sagittal axis of the tibia. The drumstick is placed in the AVF frame: proximal (ring) - distally (ring sector кольца), the supports are interconnected by three telescopic rods. In this case, two rods are installed on the outer and inner surfaces with respect to the lower leg. One rod is located on the back-outer surface of the lower leg. The needles held through the calcaneus are fixed to the distal support of the external fixation apparatus in the form of a ring sector ¾. A closed manual reposition is performed, eliminating rotational displacements at the fracture level, by centering 1 interdigital space of the foot along the line: the anterior superior iliac spine - the inner edge of the patella. Having eliminated the rotational displacements at the level of the fracture, they fix the spokes drawn through the metaphysis of the tibia to the proximal support of the AVF.

The elimination of gross displacements of fragments in the fracture area and the restoration of uniformity of the joint gap of the ankle joint is associated with the effect of ligamentotaxis, which is carried out both due to the direction of the spoke through the calcaneus (at an angle to the frontal plane of the ankle joint), and due to the greater degree of distraction along the telescopic rods . Upon reaching a satisfactory position of the fragments through the proximal metaphysis of the tibia and calcaneus spend additional knitting needles, at an angle to the previously held, to stabilize AVF. Conduct phased x-ray control.

In an emergency room, the average time of surgery is 20-30 minutes.

Clinical example of the method

Patient I. was admitted to the admission department with a diagnosis established by radiography: "An open comminuted fracture of the distal epimetaphysis of the left tibia, a fracture of the lower third of the diaphysis of the fibula (Fig. 1, 2).

In the emergency room, a distraction AVF was assembled from a standard set of Ilizarov apparatus.

The patient on the operating table, in the supine position, under spinal anesthesia through the middle of the calcaneus from the outside inward at an angle of about 14 ° to the frontal plane of the ankle joint had a 2 mm needle. Then a 2 mm spoke was held at the tibial tuberosity level perpendicular to the sagittal axis of the tibia. The drumstick was placed in the AVF frame: the ring was proximal, and the ring sector ¾ was distally installed. The supports are interconnected by three telescopic rods. In this case, two rods are located on the outer and inner surfaces with respect to the lower leg. One rod was located on the back - outer surface of the lower leg. The needles were fixed, which was passed through the calcaneus to the distal support of the external fixation apparatus in the form of a sector in the ¾ ring. Closed manual reposition was performed, eliminating rotational displacements at the fracture level by centering 1 interdigital space of the foot along the line: anterior superior iliac spine - inner margin of the patella. Having eliminated rotational displacements at the level of the fracture, we fixed the ends of the spoke drawn through the metaphysis of the tibia to the proximal support of the AVF (Fig. 3, 4).

Conducted phased x-ray control. The average time of surgery was 20-30 minutes.

In the trauma department, the skin of the lower leg and foot, fixed in the apparatus, was cared for and the preparation for the second stage of treatment, the final osteosynthesis, was performed.

The claimed method of temporary fixation of fractures of the distal leg bones operated on 10 patients with closed and open intraarticular fractures of the distal bones. Good results were obtained in all patients: the correct axial position of the fragments with residual minimal displacements in width, the possibility of early movements in adjacent joints at the stage of preoperative preparation for the second stage of surgical treatment, the absence of psychological discomfort associated with skeletal traction, adequate care for compromised skin in region of the distal tibia.

The proposed method for temporary fixation of intraarticular fractures of the distal bones of the lower leg bones allows to optimize the management of patients by early minimally invasive closed reduction of the fracture in the AVF with a reduction in the time of application of the apparatus and the subsequent adequate preparation of the compromised skin of the leg and foot before performing the final osteosynthesis. In addition, the proposed method allows to eliminate the psychological discomfort associated with skeletal traction.

The proposed method allows to reduce the cost of treatment, the time of surgery in an emergency room and the complexity of the second stage, if necessary.

In addition, the proposed method allows, in the early stages of injury, at the first stage of treatment in the admission department, to eliminate gross rotational and axial displacements of fragments by temporary fixation of a leg fracture by distraction AVF without additional fixation of the fibula by submersible metal structures.

Claims (2)

1. The method of temporary fixation of intraarticular fractures of the distal bones of the leg, including conducting crossed needles through the tibia and heel bone, fixing the needles in the proximal and distal supports of the external fixation apparatus (AVF), performing x-ray control, characterized in that the needles are passed through the middle of the calcaneus from the outside inward at an angle of 10-15 ° to the frontal plane of the ankle joint, then the needles are held at the level of the tibial tuberosity perpendicular to the sagittal the axis of the tibia, after this the tibia is placed in the AVF frame, which is assembled from the proximal ring and the distal sector in the form ^of _3/4 rings, the latter are interconnected by telescopic rods, while two rods are installed on the outer and inner surfaces relative to the lower leg, one the rod is positioned on the posterior-outer surface of the lower leg, the knitting needle is inserted through the calcaneus, a closed manual reposition is performed, eliminating rotational displacements at the level of the fracture, by centering one of the toe gap of the foot along the line: the anterior superior iliac spine - the inner edge of the patella, eliminating the rotational displacements at the fracture level, fix the knitting needle through the metaphysis of the tibia, and then carry out the distraction until the axial relationship of the fragments of the tibia and fibula and the uniformity of the articular cavity joint, then, upon reaching the biomechanically correct position of the fragments, through the proximal metaphysis of the tibia and calcaneus carry out additional knitting needles, at an angle to the previously held, carry out phased x-ray control. 2. The method according to p. 1, characterized in that the use of spokes with a diameter of not more than two millimeters.

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