RU2578182C1 - Method of stabilisation of rib valve during floating fracture of ribs - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to thoracic surgery, particularly to methods for stabilisation of rib valve at floating fractures of ribs. In area of rib valve is incised soft tissues along an intercostals space line to level of ribs. Incision is filled with medical sponge of required shape and size. On top of incision on medical sponge is flat sponge of larger size. Providing tightness of section. For this purpose, on top of flat jaws sponge made in form of a layer of dense material of larger size, equipped with an adhesive surface by pressing adhesive surface to skin. Cut window in a projection of medical sponge. One end fitted into window of silicone tube. Providing tightness of inlet tube in bandage. Other end of silicone tube is connected to vacuum therapy. Device includes vacuum therapy to create constant negative air pressure in section.

EFFECT: method enables to reduce level of flotation costal valve, up to complete stabilisation, provides for removal of wound effluent.

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Description

The invention relates to medicine, namely to thoracic surgery, in particular to methods for stabilizing the costal valve in case of floating fractures of the ribs.

There are various methods of stabilization of the chest with a floating fracture of the ribs [1].

A known method of stabilizing a rib valve during floating rib fractures using negative air pressure (reduced pressure, vacuum, vacuum) created by the device "Cape Town Saucer" [2]. The device is made in the form of a rubber saucer-suction cup equipped with a metal axial tube. The method is as follows. The device is pressed against the soft tissues of the patient's body in the area of the costal valve. At the same time, air escapes from under the saucer-suction cup through the tube. Then the tube is sealed and axial force is applied to its end. The saucer-sucker is deformed, due to which a vacuum is created between the saucer-suction cup and soft tissues. The suction cup saucer adheres tightly to the soft tissues, and the axial force applied to the axial tube is transmitted to the soft tissues and stabilizes the rib valve located beneath them.

The disadvantages of this method [2] are the insufficient stabilization of the rib valve due to the effect on the rib valve through the thickness of the soft tissues, as well as the need to apply a static external axial force.

A known method of stabilization of the chest with a floating fracture of the ribs [3] using the apparatus of mechanical ventilation. The ventilator creates internal positive air pressure (overpressure, air injection) in the lungs at the end of exhalation. Positive air pressure prevents the flotation of the rib valve, which ensures its stabilization.

However, this method [3] requires additional surgical intervention - tracheostomy. It is unnecessarily time-consuming, for victims without acute respiratory failure, who do not need mechanical ventilation. In addition, the use of this method causes additional difficulties. The period of artificial ventilation of the lungs is extended in order to achieve internal pneumatic stabilization of the chest, the length of the patient’s stay in the intensive care unit and intensive care, and, consequently, the terms of use of complex expensive equipment - apparatus for artificial ventilation of the lungs, is increased. There are also difficulties with the mobility of the victim, since it is necessary to carry out the movement of the apparatus for artificial ventilation of the lungs.

There are various devices for vacuum therapy, designed for the vacuum treatment of purulent and necrotic wounds in their preparation for plastic closure. For example, a device for vacuum therapy of purulent wounds [4]. The device for vacuum therapy of purulent wounds contains a fine-porous porous material (foam sponge), a drainage system (silicone tubes) for the wound discharge, an insulating film (adhesive dressing) and a vacuum source. The shape and dimensions of the fine-porous porous material are individually modeled according to the size of the wound, its walls and bottom. Use the device [4] as follows. Foam sponge fits strictly on the wound surface (incision), tightly pressed to its bottom. The edges of the wound remain free to avoid maceration of the skin under the foam sponge. A sterile adhesive film (adhesive dressing) to isolate the surgical field sequentially, as it adheres to the skin, is released from the protective layer. The film is hermetically applied to the skin around the wound, to the drainage tubes in those places where they "exit" from the foam sponge, and to the foam sponge itself. Drainage tubes are connected to a centralized vacuum source. A vacuum of 125 mmHg is created. An additional bandage in the form of a gauze bandage is applied on top of the tubes and the film.

However, this analogue [4] is not intended to stabilize the chest with a floating rib fracture. The purpose of the device for vacuum therapy of purulent wounds does not imply its use to reduce the level of flotation of the costal valve in case of chest fractures.

A known method for the treatment of terminal floating fractures of the ribs [5]. The method [5] includes fixing the fragments of the ribs relative to each other by pressing them to an external solid plate (hermetic bandage) using negative (reduced) air pressure. The plate is applied to the chest, the cavity formed by the plate and the patient’s body is sealed. The pressing of the fragments of the ribs to the inner surface of the plate is carried out by creating a vacuum (vacuum of air, negative pressure) in the cavity between the patient’s body and the solid plate.

This method [5] is selected as a prototype. The disadvantage of this method [5] is the insufficient stabilization of the rib valve due to exposure to the rib valve through the thickness of soft tissues. In addition, the use of this method does not allow the use of vacuum therapy in the field of soft tissue damage in order to combat pathogenic microflora, remove wound exudate, remove pus particles and dead tissue, and remove edema, since it does not involve performing a soft tissue incision in the area of the costal valve .

Tasks to be solved by the invention. In patients with floating rib fractures at the stage of preoperative preparation, in the acute period of trauma, before the operative fixation of the costal valve, the temporal stabilization of the costal valve, the fight against pathogenic microflora, removal of wound exudate, and removal of swelling are simultaneously provided. To ensure stabilization of the costal valve, prevention of suppuration of soft tissues by removing hematomas of soft tissues in the area of the costal valve in patients with a floating fracture of the chest, which is contraindicated in surgery for the purpose of osseous fixation of the costal valve. Provide regression of the phenomenon of paradoxical breathing and improve respiratory performance.

The technical result is a decrease in the level of flotation of the rib valve, up to complete stabilization, removal of wound exudate.

The specified technical result is achieved by the fact that in the method of stabilizing the rib valve during float fracture of the ribs, including the use of constant external negative air pressure, a layer-by-layer section of soft tissues along the intercostal space to the level of the ribs is made in the region of the rib valve. The incision is filled with a medical sponge of the required shape and size. On top of the incision, a larger flat sponge is placed on the medical sponge. The incision is sealed, for this purpose a dressing is applied over a flat sponge made in the form of a layer of dense material of a larger size provided with an adhesive surface, pressing the adhesive surface to the skin. A window is cut out in a blindfold, in the projection of a medical sponge. One end of the silicone tube is installed in the window. Ensure tightness of the entrance of the tube into the bandage. The other end of the silicone tube is connected to a vacuum therapy apparatus. Turn on the apparatus of vacuum therapy, creating a constant negative air pressure in the section.

The specified set of features ensures the achievement of the claimed technical result.

The invention is illustrated by the description, clinical example and illustrations, which depict:

FIG. 1 is a diagram illustrating a vacuum therapy apparatus connected by a silicone tube with an incision in the area of the costal valve, the incision is filled with a medical sponge, the dressing is not shown.

FIG. 2 is a clinical example, a photograph of a patient with a floating rib fracture.

The method is as follows.

The method is implemented as one of the stages of treatment of patients with floating rib fracture. The method is carried out as a preoperative preparation before operative osseous fixation of the costal valve in patients in a state of shock during the acute period of trauma, who are to be transported to a specialized multidisciplinary hospital for further surgical treatment. Also, the method is carried out in patients in whom surgical intervention for osseous fixation of the rib valve is associated with a high risk for life, for this category of victims the method can be used as the final way to stabilize the chest.

Based on the data of clinical, radiological and computer examinations, the region of the costal valve 1 is determined (Fig. 1) - the zone of the greatest flotation of costal fragments. In patients undergoing mechanical ventilation, general anesthesia is performed by inhalation or intravenous anesthesia. Victims without acute respiratory failure undergo total intravenous anesthesia without intubation of the trachea. The surgical field is treated with antiseptic solutions. In the region of the costal valve, a layer-by-layer incision 2 (Fig. 1) of soft tissues along the intercostal space is made to the level of ribs 3 (Fig. 1). Cut the skin, subcutaneous tissue, fascia, superficial and deep muscles, expose the area of fracture of the ribs. The length of the incision is up to 10 cm. The incision is filled with a medical sponge 4 (Fig. 1) of the required shape and size. Use a sterile sponge, give it the necessary shape and size, place it between the walls and the bottom into the cut, filling the contours of the cut. A flat sponge is placed on top of the incision on the medical sponge, overlapping the transverse dimensions of the underlying one. The incision is sealed, for this purpose a dressing is applied over a flat sponge made in the form of a layer of dense material of a larger size provided with an adhesive surface, pressing the adhesive surface to the skin. A sterile adhesive film can be used as a dressing. The surgical field around the incision with jaws installed in it is glued with an adhesive film to ensure tightness. A window is cut out in a blindfold, in the projection of a medical sponge. One end of the silicone tube 5 is installed in the window (Fig. 1). Ensure tightness of the entrance of the tube into the bandage. For this, after installing the tube over it, a second layer of adhesive film can be glued. The other end of the silicone tube is connected to a vacuum therapy apparatus 6 (Fig. 1). The vacuum therapy apparatus is turned on, the necessary constant negative (lowered) air pressure is established (within 80-120 mm Hg). The vacuum therapy apparatus through a silicone tube creates a decrease in pressure (vacuum) in the section under an airtight dressing. The effect of lowering the pressure in the section is evaluated by compaction and compression of the sponge under the bandage. When the internal pressure on the rib valve exceeds the pressure on the rib valve from the side of the incision, it is pressed against the soft tissues. This reduces the level of flotation of the costal valve during inhalation and exhalation of the victim. The position of the rib valve is stabilized. The effect of stabilization of the costal valve is assessed by regression of the phenomena of paradoxical respiration and improvement of respiratory performance. In this case, the constant negative (lowered) air pressure in the section and in the silicone tube causes the wound exudate to separate from the section and advance along the silicone tube into the capacity of the vacuum therapy apparatus. Using this method with a vacuum therapy device allows the movement of the victim, since vacuum therapy devices are small-sized mobile devices.

Clinical example.

Patient M., 49 years old, received traumatic injuries of the central nervous system, chest and right thigh as a result of a traffic accident on March 23, 2014. He was hospitalized in the central district hospital nearby to the scene of the accident, where he was diagnosed after an additional examination: Combined injury . Closed head injury. Brain concussion. Closed chest injury. Multiple floating rib fractures on the right (IV to IX). Hemopneumothorax on the right. Acute respiratory failure. Closed fracture of the middle third of the right with the displacement of fragments. Traumatic shock of 1 degree.

The following emergency procedures were performed for the patient: thoracocentesis on the right, pleural cavity drainage, skeletal traction over the femoral condyle. Given the phenomena of respiratory failure, the patient was intubated with a trachea and the patient was transferred to artificial lung ventilation. Subsequent therapy included anti-shock measures. In order to determine further tactics of treating the patient and possible transportation to a specialized department, a thoracic surgeon from a regional hospital was called for consultation.

Examination of the thoracic surgeon 6 hours after the injury revealed the preservation of paradoxical breathing in the victim, despite the mechanical ventilation of the lungs. An antero-lateral costal valve was diagnosed in the projection of the IV-VI ribs. Given the patient’s serious condition and unstable hemodynamic parameters, it was decided to stabilize the rib valve using a vacuum therapy apparatus. Spent treatment of the surgical field with antiseptic solutions. Under local anesthesia, a layered soft tissue incision was made in the area of the costal valve, in the projection of floating IV-VI rib fractures, along the intercostal space, the cut length was 8 cm, the area of the fracture of the ribs (fragmentation zone) was exposed. The incision was filled with a sterile medical sponge, giving it the necessary shape and size. A flat sponge was placed on top of the incision on a medical sponge. An airtight adhesive tape was applied over the flat sponge. A window was cut out in a blindfold, in the projection of a medical sponge. One end of the silicone tube of the vacuum therapy apparatus was installed in the window. The entry point (window) of the silicone tube was sealed with an adhesive film. The other end of the silicone tube was connected to a vacuum therapy apparatus (Fig. 2). The vacuum therapy apparatus was turned on by setting the necessary constant negative (lowered) air pressure equal to 100 mm Hg. The effect of lowering the pressure in the section was evaluated by compaction and compression of the sponge under the dressing.

2 hours after turning on the vacuum therapy apparatus, the cessation of paradoxical movements of the chest was noted, the level of flotation of the rib valve decreased, and hemodynamic parameters stabilized. During the day, the patient was treated at the Central Hospital, then, accompanied by a resuscitator, he was taken to the regional hospital, while stabilization of the costal valve was maintained using a vacuum therapy apparatus.

The patient underwent computed tomography of the chest, which confirmed the resolution of hemopneumothorax and the absence of trauma to the lung tissue with fragments of the ribs. The patient's condition improved, stability of the configuration and volume of the chest was noted. Upon reaching the normalization of the parameters of the gas composition of the blood, oxygen saturation of the blood after 2 days, the patient was transferred to auxiliary ventilation modes and then extubated. Subsequent spontaneous breathing was adequate, fully meeting the needs of the patient's body. The vacuum therapy apparatus functioned for another 2 days after disconnecting the patient from mechanical ventilation. Moreover, with its help, about 150-200 ml of soft tissue hematoma was also evacuated daily. The patient slowly activated. After removal of the vacuum therapy apparatus on the 4th day from the injury, second-delayed sutures were applied to the wound. There was no need for further stabilization. Confirmation of the effectiveness of stabilization of the costal valve was: expansion of the right lung on the x-ray, normal oxygenation and gas composition of the blood. The need for additional methods of stabilization or fixation of the costal valve in this patient did not arise. As treatment was completed in the thoracic department, the patient was transferred to the department of traumatology for further treatment of a hip fracture.

Information sources

1. Historical review of treatment methods for fractures of the ribs of the rib cage / M. Bemelman [et al.] // European Journal of Traumatology and Emergency Surgery. October 2010, pp. 407-415.

English: Historic overview of treatment techniques for rib fractures and flail chest / M. Bemelman, M. Poeze, T.J. Blokhuis, L.P.H. Leenen. // European Journal of Trauma and Emergency Surgery. Eur J Trauma Emerg Surg. Oct 2010; page 407-415. PubMed-PMCID: PMC 3150827.

2. Control of chest fractures. Using the device "Sare Town Limpet" / T. Shreir. // South African Medical Journal. June 1962 S. 516-518.

English: Control of the stove-in (flail) chest. The use of the “sare town limpet” / T. Schrire. // S.A. Medical journal. Junie 1962; page 516-518. PubMed - PMID: 14051600.

3. Wagner E.A. Breast Damage Surgery. - M .: Medicine, 1981. - S. 61-63, 76, 90-91,129-136. - 288.

4. A device for vacuum therapy of purulent wounds. RF patent for PM RU 70627 U1. IPC A61M 27/00. Posted: 02/10/2008.

5. A method for the treatment of terminal floating fractures of ribs. RF patent for IZ RU 2206294 C2. IPC 7 A61F 5/00, A61F 5/449. Published: June 20, 2003.

Claims (1)

A method of stabilizing a rib valve in case of a floating fracture of the ribs, comprising applying a constant external negative air pressure, characterized in that in the region of the rib valve a soft tissue layer-by-layer incision is made along the intercostal space to the level of the ribs, the incision is filled with a medical sponge of the required shape and size, on top of the incision for medical a sponge is applied with a larger flat sponge, ensures a cut is sealed, for this a bandage made in the form of a layer of raft is applied over a flat sponge of a larger material equipped with an adhesive surface, pressing the adhesive surface against the skin, a window is cut into the bandage of the medical sponge in the bandage, one end of the silicone tube is installed in the window, the tube is sealed to the bandage, the other end of the silicone tube is connected to the vacuum therapy apparatus, vacuum therapy apparatus, creating a constant negative air pressure in the section.

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