RU2585738C1 - Method for ulnar counter-support branch - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, particularly to reconstructive hand surgery. Method includes forming soft-tissue frame of ulnar border of hand due to Converse-Blokhin double flap. Osteotomy of forth metacarpal bone. Performing distraction of its distal fragment and moving on fifth metacarpal bone stump. Method then includes osteotomy of third metacarpal bone distraction is its distal fragment and moving distracted fragment of third metacarpal bone on distal end of forth metacarpal bone fragment, previously moved onto stump of fifth metacarpal bone.

EFFECT: method restores stability of grip using local donor resources.

1 cl, 1 ex, 6 dwg

Description

The invention relates to medicine, namely to reconstructive surgery of the hand.

There is a method of reconstructing the ulnar antitumor jaw while maintaining the first finger or most of it, in which a distraction apparatus is applied to the stump of the metacarpal bone, the metadiaphyseal zone is closed by distraction, then the formation of a distraction regenerate of the required length is achieved (AS No. 1117049, 1982) .

The method has the following disadvantages: 1) rupture of the meta-diaphyseal zone is possible only in children; 2) the formation of distraction regenerate takes a long time; 3) fractures of distraction regenerate, the formation of false joints are possible; 4) the method cannot be used to lengthen the short stumps of the metacarpal bones.

As a prototype, a method was selected consisting in performing an osteotomy of the stump of the metacarpal bone, distraction of its distal fragment using an external fixation apparatus and moving the distal fragment to the recipient stump using an avascular bone cortical-spongy graft located between the elongated and displaced stumps (RF patent 2120246, 1998).

The method has the following disadvantages: 1) it does not make it possible to restore sufficient stability of the grip of the hand, since the used avascular bone graft is fused with the recipient bed and rebuilt for a long time; 2) fractures and the formation of pseudograft joints are possible, which requires repeated bone grafting; 3) in the presence of extensive cicatricial changes in the soft tissues of the stump end region, it is possible to prolapse the distal end of the distractable fragment, which lengthens the treatment time; 4) a donor defect is applied during bone graft collection.

The task of the invention is to improve the method.

The technical result is the restoration of stability of the grip of the brush using local donor resources.

The technical result is achieved due to the fact that in a method including osteotomy of the stump of the metacarpal bone, distraction of its distal fragment by the external fixation apparatus and its movement to the recipient stump, the soft tissue skeleton of the ulnar edge of the hand is preliminarily formed with a double Converse-Blokhin flap, osteotomy of the fourth stump of the stump is performed bones, carry out the distraction of its distal fragment and move it to the stump of the fifth metacarpal bone, then make an osteotomy of the stump of the third metacarpal bone, suppl distraction its distal fragment and the fragment is moved distragirovanny third metacarpal bone on the distal end of the stump fragment fourth metacarpal bones, previously moved on the stump of the fifth metacarpal.

The method is illustrated by drawings, where in FIG. 1 shows the formed soft tissue skeleton of the elbow edge of the brush; in FIG. 2 - osteotomy of the stump of the fourth metacarpal bone, conducting axial distracting spokes with a thrust pad and a screw rod; in FIG. 3 - the stump of the fourth metacarpal bone moved to the stump of the fifth metacarpal bone; in FIG. 4 - osteotomy of the stump of the third metacarpal bone, conducting axial distracting spokes with a thrust pad and a screw rod; in FIG. 5 - complete distraction of the stump of the third metacarpal bone; in FIG. 6 - lengthening of the stump of the fifth metacarpal bone due to the movement of fragments of the fourth and third metacarpal bones.

The method is as follows.

At the ends of the stumps of 2-5 metacarpal bones, scars are excised, plastic stump is performed with a double Converse-Blokhin rag and a soft-tissue skeleton of the formed branch 1 is created (Fig. 1). A layered incision of the skin and underlying tissues is performed on the back surface of the hand in the projection of the fourth intercarpal gap. An osteotomy of the stump of the fourth metacarpal bone 2 is performed at the level of the proximal metaepiphysis or exarticulation in the carpal-metacarpal joint in the presence of a short stump of the metacarpal bone. Through the distal fragment of the metacarpal bone, an intramedullary and formed soft-tissue skeleton is passed through the Kirschner needle with the formation of a thrust pad at the proximal end. On the forearm in the region of its distal third spend crossing needles, which are fixed in the ring of the Ilizarov apparatus. A U-shaped frame with a screw rod 3 is mounted to the ring. The distal end of the spoke is fixed to the screw rod 3 of the external fixation device (Fig. 2). Perform a layered suture of the wound. After 3 days, axial distraction of the distal metacarpal fragment begins at 1-2 mm per day. The distraction is performed to such an extent that the proximal end of the distracted fragment of the metacarpal bone is at the level of the distal end of the stump of the fifth metacarpal bone. After completion of the distraction, the screw rod of the external fixation apparatus is dismantled. Next, an incision is made in the area of the postoperative scar. The end of the stump of the fifth metacarpal bone is isolated and refreshed. The distracted fragment of the fourth metacarpal bone 2 is moved to the stump of the fifth metacarpal bone and their osteosynthesis is performed with crossed knitting needles (Fig. 3). Perform a layered incision in the projection of the third metacarpal bone 4. Perform its transverse osteotomy or exarticulation in the carpal-metacarpal joint, depending on the length of the metacarpal stump. Similarly, the needle is carried out intramedullary and fixed to the screw rod 3 of the external fixation device (Fig. 4). The surgical wound is sutured. After 3 days, axial distraction of the distal fragment of the third metacarpal bone 4 begins, 1-2 mm per day. The distraction is carried out to such an extent that the proximal end of the distracted fragment of the stump of the third metacarpal bone 4 is at the level of the distal end of the displaced stump of the fourth metacarpal bone 2 (Fig. 5). Next, remove the external fixation device. An incision is made in the region of the second postoperative wound, the distal end of the displaced stump of the fourth metacarpal bone is isolated and refreshed 2. The distal fragment of the third metacarpal bone 4 is moved to the distal end of the stump of the fourth metacarpal bone 2, which was previously moved to the stump of the fifth metacarpal bone, and their osteosynthesis is performed by knitting (Fig. 6). Heal the postoperative wound. The brush is fixed with a plaster cast until the consolidation of the displaced fragments of the metacarpal bones occurs.

Clinical example

Patient A. A. A., was in the microsurgical department of the Nizhny Novgorod Scientific Research Institute of Nuclear Medicine with a diagnosis of stump of 2-5 metacarpal bones of the left hand at the level of the proximal and middle third of the metacarpal bones. From the anamnesis it is known that 2-5 fingers of the left hand fell under a hot press. The patient underwent staged necrectomy and free skin grafting of granulating wounds. Upon admission to the clinic, extensive skin scars on the back and palmar surfaces of the stumps of 2-5 metacarpal bones are noted. Previously, the patient underwent excision of scars on the stump of 2-5 metacarpal bones and the replacement of soft tissue defect with a double Converse-Blokhin flap with the creation of a reserve of soft tissues at the ends of the stumps of 2-5 metacarpal bones (03/11/09). When the patient was re-admitted, an osteotomy of the fourth metacarpal bone was performed, distal fragment of it was distracted using an external fixation apparatus, and the fragment was moved to the stump of the fifth metacarpal bone (06/23/09). Without removing the external fixation apparatus, an osteotomy of the stump of the third metacarpal bone was performed and its distal fragment was moved to the displaced stump of the fourth metacarpal bone (07/23/09).

The patient was examined 3 years after surgery. Complete consolidation of bone fragments is noted. The length of the formed ulnar anti-resistant jaw is equal to the length of the first finger with the metacarpal bone and is 11 cm. The grip of the hand is restored: it is possible to bring the first finger to the formed jaw and contrast the first finger with the jaw. The opening of the first finger relative to the jaw is 10 cm. The patient uses the operated brush in domestic and industrial activities.

When the method is implemented, the stability of the grip of the brush using local donor resources is restored, reliable consolidation of bone fragments of the type of primary healing in the usual time and the creation of the ulnar anticorrosion jaw equal to the first finger are ensured.

Adequate blood supply to bone fragments is achieved, which excludes long periods of reconstruction and prolongation of treatment time, while ensuring sufficient strength of the bone skeleton of the formed anti-resistant jaw and its resistance to resorption.

In addition, an adequate soft-tissue skeleton of the ulnar anti-resistant jaw is created, which ensures the prevention of ulceration and prolapse of the bone skeleton on the butt surface of the jaw.

The method eliminates the damage to remote donor areas.

Claims (1)

A method for reconstructing the ulnar antitumor jaw, including an osteotomy of the metacarpal stump, distraction of the distal metacarpal fragment using an external fixation apparatus and moving it to the recipient stump, characterized in that the soft tissue skeleton of the ulnar edge of the hand is previously formed due to the double Converse-Blokhin flap, and stumps of the fourth metacarpal bone, distill its distal fragment and carry it to the stump of the fifth metacarpal bone, then osteotomy five third metacarpal bone distraction operate its distal fragment and the fragment is moved distragirovanny third metacarpal bone on the distal end of the stump fragment fourth metacarpal bones, previously moved on the stump of the fifth metacarpal.

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