RU2570770C1 - Method for thumb formation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: under regional anaesthesia, a fasciocutaneous flap is separated from a dorsal approach in a second intermetacarpal space on the periphery on a third metacarpal. A dorsal transverse artery of wrist with accompanying veins is separated and ligatured twice, and transected in between. A second metacarpal graft vascularised by a second metacarpal artery, which is a branch of the dorsal transverse artery of wrist is transplanted on a thumb stump. The transplanted graft is fixed with wires.

EFFECT: method prevents reducing the blood flow of wrist, creates the adequate shape of the thumb, ensures the complete discrimination sensitivity and resistance to mechanical injuries.

10 dwg, 1 ex

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used to form the lost first finger of the brush.

For the treatment of such injuries, the operation of the phalanx of the I metacarpal bone is used, which consists in the intersection of the bundles of the right dorsal interosseous and short adductor muscles in order to release the I metacarpal bone and deepen the first interdigital space (P. C. Huguior. Considerations anatomiques et physiologiques pourservir a la chirurgie du pouce. Arch. Gen. Med. - 1874. - Vol. I. - 78-82). However, after the operation, objects are held between the lateral surfaces of the first and second metacarpal bones and the force of the “created” I finger is weakened.

There is a method of restoring the first finger by transplanting a radial flap, which consists in the fact that a skin-fascial flap is isolated in the upper third of the forearm, the radial artery is ligated, and a graft is formed from the site of the radius in the lower third of the forearm. The isolated tissue complex is rotated through 180 °, the skin-fascial flap is wrapped around the formed bone graft and introduced into the bone marrow canal of the stump. After graft engraftment, several modeling operations on integumentary tissues are performed (G. Foucher et al. Single stage thumb reconstruction by a composit forearm island flap. The journal of hand surgery, Vol. 9-B, No. 3, october 1984, p. 245- 248).

The disadvantages of this method are as follows. Ligation of the radial artery leads to a decrease in volumetric blood flow of the hand. As a result of this, the “stealing" syndrome develops, which is manifested in chilliness, decreased strength, decreased sensitivity, parasthesia, thinning of the skin, and a decrease in subcutaneous fat. The absence of a nerve in the skin-fascial flap leads to a sensitivity disorder. A shapeless finger is formed that does not have discriminatory sensitivity. A transplant of a forearm skin that is unstable to mechanical injury prevents the performance of loads. Repeated operations are performed to reduce the size and shape the first finger.

Closest to the proposed one is the method when the stalk of Filatov is formed on the stomach, the stalk is migrated to the hand. After 2 months, a longitudinal osteotomy of the second metacarpal bone is performed, its palm fragment is transferred to the stump of the first bone on the palmar feeding leg (RU 2460487, publ. 09/10/2012). The opposed counterpart has the following disadvantages:

1. The duration of treatment of the patient. After the formation of the Filatov stem on the stomach, the stem is migrated to the hand, and the formation of the first finger begins in 2 months. The operation is characterized by multi-stage, traumatism and technical complexity.

2. Transplanted skin is unstable to mechanical injury and prevents mechanical stress.

3. A shapeless finger forms.

4. In the description of the invention presents only the scheme of operation.

Radiographs, photographs of surgical interventions and the appearance of the hand before and after the operation, confirming the described methods, are not shown.

The aim of the proposed method is to improve the results and reduce treatment time by preventing the reduction of volumetric blood flow of the hand, the formation of the finger of the hand, having the proper shape, full discriminatory sensitivity and resistance to mechanical injury.

The technical result of the task is achieved by the fact that under conduction anesthesia with back access in the second intercarpal gap along the edge of the third metacarpal bone, a skin-fascial flap of the second finger is isolated. The second metocarpal artery is traced under a microscope, the back transverse artery of the wrist is ligated and cut off at the level of the second intercarpal gap. The second metacarpal bone with integumentary tissues is able to move toward the first metacarpal bone and distally. Blood supply to the transplanted II metacarpal bone is via the II metacarpal artery, which is a branch of the dorsal transverse artery of the wrist. Surgery allows you to increase the size of the first intercarpal gap, necessary to improve the function of the grip of the hand. The second metacarpal bone with a skin-fascial flap is moved to the end face of the sawn stump of the first metacarpal bone and the transplanted graft is fixed with two knitting needles. To stabilize the first metacarpal bone, a spoke is passed through it and the radius. The transplanted metacarpal II on the palmar side is covered with a previously separated and displaced excess of soft tissue from the stump of the 1st metacarpal bone on the palmar side, which is sutured with soft tissues of the posterior flap of the second metacarpal bone, covering the back of the graft.

To justify the method of forming the first finger of the hand, the topographic anatomy of the back artery of the wrist, which gives branches to the metacarpal bones, was studied. It was found that the branches enter the metacarpal bones in the area of their base, while the filiform vessels spread along the periosteum throughout the metacarpal bone. The back artery of the wrist is the connecting vessel between the deep branch of the radial artery and the back branch of the ulnar artery. The diameter of the back artery of the wrist was measured by cutting out the template and combining the latter with a micrometer under a microscope with a magnification of × 12. The diameter was 0.15-0.20 mm; the diameter of the dorsal metacarpal branches was 0.1-0.15 mm. The back artery of the wrist, running in the transverse direction, can be dissected from the underlying tissues - the periosteum of the small bones of the wrist along with the accompanying veins. Taking into account the double blood supply of this artery, it can be bandaged in the second or third metacarpal spaces and mobilized together with the metacarpal bone. The measured permissible displacement length was: on two preparations - 33-35 mm; on three drugs - 29-33 mm. The mobilization of the skin flap covering the metacarpal bone is accompanied by a deepening of the metacarpal gap by 22-25 mm.

Conducted an experimental operation as follows. The metacarpal bone was isolated from its bed in a figured incision in the intercarpal spaces with the transition to the back surface of the hand. Using the operating magnifier, the back artery of the wrist above the third metacarpal bone was isolated and ligated, and, dissecting it together with the second metacarpal artery, the tissue complex was moved to the prepared surface of the stump of the first finger, where it was fixed with two knitting needles (Fig. 1, Fig. 2). 4 operations completed. The elongation of the finger stump was 29-34 mm.

Isolation of the vessels of the periosteum requires thoroughness and caution in handling the vascular pedicle.

The drawings show:

FIG. 1. Scheme of transplantation of the second metacarpal bone on the stump of the first finger. The arrows indicate: 1 - the stump of the second finger: the dashed lines mark the boundaries of the tissue complex; 2 - the back artery of the wrist; 3 - metacarpal arteries; 4 - place of ligation of the back artery of the wrist; 5 - direction of movement of the blood supply complex of tissues; 6 - levels of osteotomy of the II metacarpal bone.

FIG. 2. Scheme of transplantation of the second metacarpal bone on the stump of the first finger. The back artery of the wrist is crossed and moved. Arrows indicate: 1 - bandaged back artery of the wrist; 2 - displaced artery of the wrist with a metacarpal artery; 3 - displaced transplant of the II metacarpal bone; 4 - fixing knitting needles.

FIG. 3. Radiograph of the hand after injury.

FIG. 4. Radiograph of the hand after surgical treatment.

FIG. 5. Type of brush (back and palm surface).

FIG. 6. Angiogram of the hand and forearm. The arrow shows the second metocarpal artery.

FIG. 7. Preoperative marking of the surgical field.

FIG. 8. Radiographs after surgery.

FIG. 9. Type of brush after surgery.

FIG. 10. View of the brush after 12 days.

CLINICAL OBSERVATION

V., 24 years old, was admitted for a stump of the first finger, lack of II-IV rays, a chronic dislocation of the fourth metacarpal bone of the right hand (Fig. 3, Fig. 4). The primary surgical treatment of the wound. Stumps of the first, second, third and fourth fingers are formed. In connection with the short stumps of the metacarpal bones of the I, II, III, IV fingers, there was no grip of the hand. To study the location of the vessels of the hand and forearm, angiography was performed, it was found that the second metacarpal artery, which is a branch of the back artery of the wrist, was preserved (Fig. 6). On March 12, 12, the developed operation was completed. A skin-fascial flap was isolated under conduction anesthesia by the rear access in the second intercarpal gap along the edge of the third metacarpal bone. Under the microscope, the II metacarpal artery was traced, which provides blood supply to the II metacarpal bone. The latter is bandaged between the second and third inter-metacarpal spaces. The skin-fascial flap with the II metacarpal bone received mobility. This allowed to move the II metacarpal bone with a skin-fascial flap on the end face of the sawn stump of the I metacarpal bone and fix the bone part of the graft with 2 knitting needles. To stabilize the first metacarpal bone, a spoke was drawn through it and the radius. The first metacarpal bone is covered with a previously transplanted excess of soft tissues on the metacarpal stump on the palmar side, which are stitched with soft tissues of the posterior flap of the second metacarpal bone. When filing the base of the second metacarpal bone, bleeding from the spongy part of the bone was noted, which indicates the preservation of its blood supply. The resulting defect of the I metacarpal gap after transplantation of the second metacarpal bone is closed by mobilization of the edges of the flaps, as well as by a split dermatome graft taken from the forearm. The length of the bone graft of the II metacarpal bone is 32 mm, the length of the I beam, consisting of the I metacarpal bone and the transplanted transplant of the II metacarpal bone, was 9.5 cm, which is 1.5 cm less than the length of the I finger on a healthy arm (Fig. 8) . A dermatomic graft is fixed to the edges of the skin defect of the first intercarpal space. The brush is immobilized with a plaster cast (Fig. 9, Fig. 10). According to the described technique, 5 patients were operated on. The engraftment of transplanted grafts began. There were no complications.

In the available literature, it was not possible to find publications similar to the proposed methodology.

Claims (1)

The method of forming the first finger of the hand, including transplanting a bone graft in a skin-fascial flap onto a stump of the first metacarpal bone, as well as introducing a bone graft into the medullary canal of the stump, characterized in that the dorsal transverse artery of the wrist with accompanying veins is isolated and ligated with two ligatures, and they cross between them, a transplant of the second metacarpal bone is transplanted onto the stump of the first finger, the blood supply to the second metacarpal artery, which is the transverse dorsal branch th artery of the wrist, and fix the transplanted graft with knitting needles.

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