RU2594444C1 - Method of minimally invasive external fixation in fractures of diaphysis and surgical neck of humerus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to traumatology and orthopaedics and can be applied for minimally invasive external fixation in fractures of diaphysis and surgical neck of humerus. Linear plate of selected length is simulated depending on the nature and localisation of the fracture, bending it along the humerus model, balanced with the injured patient's bone. In compliance with simulated plate ends location, markings and projections of proximal and distal surgical approaches are marked on the skin of patient's arm. Plate is introduced from the proximal approach under a deltoid muscle and axillary nerve, performing palpatory control to prevent damages, and then the plate is extraperiosteally introduced above the fracture zone. Distal end of the plate in the wound is visualized and it is oriented along the anterior surface of humerus in the lower third of its diaphysis. Bone fragments are finally repositioned and fixed.

EFFECT: method enables reducing a risk of vessels and nerves injuries, increasing the fixation stability.

1 cl, 20 dwg

Description

The invention relates to medicine, in particular to traumatology and orthopedics, and can be used in the treatment of patients with fractures of all departments of the diaphysis of the humerus, as well as its surgical neck.

The prevalence of fractures of the diaphysis of the humerus is 3-5% of all skeleton fractures (1). Conservative treatment of isolated low-energy fractures of the diaphysis of the humerus with moderate displacement of bone fragments has not lost its relevance and gives good results. However, surgical treatment of victims with such fractures, especially with high-energy injuries and a significant displacement of bone fragments, provides faster and better restoration of the function of the damaged limb (2). The main types of surgical treatment for these patients are the methods of internal bone or intramedullary osteosynthesis. External fixation devices are used for the considered fractures only when it is impossible to perform internal osteosynthesis in cases of severe damage to soft tissues, infected fractures, as well as in the presence of large bone defects.

It should be noted that traditional bone marrow osteosynthesis is performed from the anterior, anterolateral, lateral, or posterior approaches and involves extensive exposure of the fracture zone for open reduction of bone fragments. In this case, their blood supply is inevitably disrupted, which leads to a high risk of nonunion fractures (up to 5.8%) (3), infectious complications and repeated fractures after removal of the fixators (4). In addition, in such operations, iatrogenic damage to the radial nerve is quite common: in 5.1-17.6% of cases (3).

Intramedullary osteosynthesis also has its drawbacks in the treatment of patients with fractures of the diaphysis of the humerus. With antegrade introduction of an intramedullary shaft, damage to the cartilage of the humeral head, trauma to the structures of the rotational cuff and tendon of the long head of the biceps of the shoulder muscle are possible (5, 6). A frequent complication of antegrade intramedullary osteosynthesis of the humerus is also the shoulder impediment, manifested by chronic pain (7). With a closed reposition of fragments due to traction or pinching between the ends of the bone fragments, iatrogenic damage to the radial nerve is possible. In addition, with proximal blocking, there is a risk of damage to the axillary nerve, with distal - brachial artery and radial nerve.

Retrograde intramedullary osteosynthesis with diaphyseal fractures of the humerus also has specific disadvantages. This is the need for laying the patient on the abdomen or on the side, significant damage to the capsule of the elbow joint and the real danger of iatrogenic condyle and supracondylar fractures with the introduction of a rigid intramedullary shaft (8). In addition, intramedullary osteosynthesis often does not allow for sufficient rotational stability and interfragmental compression during transverse and short oblique fractures (type A according to the classification of the Osteosynthesis Association - AO). The consequence of this may be nonunion fractures, usually requiring repeated surgical interventions using bone grafting and the installation of additional metal structures (7).

However, a method is known for minimally invasive humerus osteosynthesis of the humerus with a linear plate that is inserted and fixed through two incisions of the skin and soft tissues outside the fracture zone on the anterior surface of the shoulder in its upper and lower thirds, and then is installed (positioned) on the anterior surface of the humerus. This technique was proposed by B. Livani et W.D. Belangero in 2004 (9). However, this method does not allow to fix high fractures of the diaphysis of the humerus, as well as their combination with fractures of the surgical neck of the humerus due to the conflict of the plate with the tendon of the long head of the biceps of the shoulder.

Therefore, for surgical treatment of patients with fractures of the proximal humerus through minimally invasive osseous A.A. Fernandes Dell′Osa (10), and then other authors (11) proposed the use of spiral curved plates. At the same time, the upper part of such plates is positioned along the lateral surface of the proximal humerus, and the lower is located on the front surface of its diaphysis, which eliminates the conflict of the plates with the tendon of the long head of the biceps of the shoulder. However, these authors consider their proposed osteosynthesis techniques only for fractures of the humerus in the upper third of its diaphysis, but not along its entire length. This is due to a lack of information about the relationship of a spirally curved plate of a relatively greater length with the axillary, radial and musculocutaneous nerves, as well as with the main blood vessels: the brachial and deep arteries of the shoulder with concomitant veins of the same name, which can be damaged by such a plate at the level of the middle and lower third diaphysis of the humerus.

In view of the foregoing, the object of the present invention is to develop an effective and safe technique for minimally invasive stable fixation of bone fragments during fractures of all sections of the diaphysis of the humerus, as well as in combination with fractures of its surgical neck.

The technical result of the invention consists in minimally invasive, stable fixation of fragments of the humerus during fractures of its diaphysis in any department, as well as in the combination of such fractures with fractures of its surgical neck. Moreover, due to the bridge-like principle of fixation, the fracture zone is not exposed, which ensures the preservation of periosteal blood supply of bone fragments and helps to optimize the processes of reparative regeneration of bone tissue in the fracture zone. Due to the special spiral modeling of the plate and the original technique of its implantation, the proposed method eliminates damage using the fixative of the axillary, radiation, muscle-cutaneous and median nerves; brachial artery, deep artery of the shoulder and related veins of the same name; and also to prevent the conflict of the plate with the tendon of the long head of the biceps of the shoulder.

The result of the invention is achieved due to the fact that a spirally curved plate with angular stability of the screws and pointed ends is pre-modeled by bending it according to the model of the humerus commensurate with the damaged bone of the patient, then the necessary anatomical landmarks and projections of the proximal and distal surgical approaches are marked on the skin of the shoulder, applying the simulated plate to the patient’s shoulder, then appropriate cuts are made and the plate is inserted from proximal access on the lateral surface the shoulder in its upper third, carry it under the deltoid muscle and axillary nerve, controlling it by palpation to prevent damage and then extraperiostally over the fracture zone, then visualize the distal end of the plate in the distal access wound and orient it along the front surface of the humerus in the lower third its diaphysis, after which the final reposition and fixation of bone fragments is performed, which avoids contact of the plate with the deep artery of the shoulder, brachial artery and associated vein mi, the tendon of the long head of the biceps of the shoulder, as well as the radial, muscular-cutaneous and median nerves and is confirmed by specially conducted experiments on anatomical material.

The figures depict:

Figure 1. An example of modeling (spiral bending) of a plate with angular stability of screws and pointed ends of length 260 on a model of the human humerus.

Figure 2. Marking of the necessary anatomical landmarks and projections of the proximal and distal surgical approaches on the skin of the right shoulder of the anatomical object (non-fixed corpse).

Figure 3. The result of holding the plate in the axillary tunnel of the proposed method on the right shoulder of the anatomical object.

Figure 4. Detection in the wound of distal surgical access on the shoulder of the anatomical object of the distal end of the installed plate for its final orientation on the front surface of the humerus in the lower third of its diaphysis.

Figure 5. The result of the precision preparation of the anatomical object on the right shoulder after the insertion of the plate by the proposed method: the saved axillary nerve is seen passing over the installed plate 5 cm distal to the upper end of the ruler, and the compass shows the distance from the plate to the radial nerve and the deep artery of the shoulder with its accompanying the same vein.

Figure 6. The result of precision preparation on the right shoulder of the anatomical object after installing the plate by the proposed method: the compass shows the distance from the plate to the musculocutaneous nerve, which is separated from it by the abdomen of the brachial muscle.

Figure 7. The result of precision preparation on the right shoulder of the anatomical object after installing the plate by the proposed method: the compass shows the distance from the plate to the median nerve and brachial artery with the same vein.

Figure 8. The roentgenogram of a closed comminuted fracture of the diaphysis of the left humerus with displacement of fragments, 12 B3 - according to the classification of AO, on the radiograph of patient B., 54 years old, before surgery (Clinical example 1).

Figure 9. The result of fluoroscopic intraoperative control of reposition of bone fragments and the position of the plate installed by the proposed method (Clinical example 1).

Figure 10. X-ray of the left shoulder of patient B., 54 years old, 6 weeks after surgery, direct projection: visible bone marrow in the fracture area is visible (Clinical example 1).

Figure 11. X-ray of the left shoulder of patient B., 54 years old, 6 weeks after surgery, axial projection: visible emerging bone marrow in the fracture area (Clinical example 1).

Figure 12. Radiograph of the left shoulder of patient B., 54 years old, 14 weeks after surgery by the proposed method: there are distinct signs of fracture fusion (Clinical example 1).

Figure 13. A good restoration of the function of the injured left upper limb 14 weeks after surgery by the proposed method in patient B., 54 years old, the position of the arms apart to the sides (Clinical example 1).

Figure 14. A good restoration of the function of the injured left upper limb 14 weeks after surgery by the proposed method in patient B., 54 years old, the position of raising the arms up (Clinical example 1).

Figure 15. Good restoration of the function of the injured left upper limb 14 weeks after surgery by the proposed method in patient B., 54 years old, position of the arm behind the back (Clinical example 1).

Figure 16. Radiograph of a closed comminuted fragmentary fracture of the diaphysis of the left humerus, 12 C1 - according to the classification of AO, in patient L., 20 years old, before surgery (Clinical example 2).

Figure 17. Radiograph of the left shoulder of patient L., 20 years old, 7 weeks after surgery, direct projection: the emerging bone marrow in the fracture area is visible (Clinical example 2).

Figure 18. X-ray of the left shoulder of a patient L., 20 years old, 7 weeks after surgery, axial projection: visible emerging bone marrow in the fracture area (Clinical example 2).

Figure 19. Radiograph of the left shoulder of patient L., 20 years old, 12 weeks after the operation of the proposed method, direct projection: in the fracture area in both projections bone callus is traced, indicating a fusion of the fracture (Clinical example 2).

Figure 20. Radiograph of the left shoulder of patient L., 20 years old, 12 weeks after the operation of the proposed method, axial projection: in the area of the fracture in both projections bone callus is observed, indicating the fusion of the fracture (Clinical example 2).

The features of the implant placement technique by the proposed method were studied during applied topographic and anatomical studies on eight non-fixed upper limbs. In accordance with the developed technique, at first, a straight plate with angular stability of the screws and pointed ends was helically bent according to the model (preparation) of the human humerus, commensurate with the humerus on the used non-fixed anatomical material (Fig. 1). Then, on the shoulder skin of an anatomical object (an unfixed corpse), applying a simulated plate to it, the necessary anatomical landmarks and projections of the proximal and distal surgical approaches were outlined (Fig. 2). Next, the corresponding incisions were made and a plate was inserted from the proximal access on the lateral surface of the shoulder in its upper third, it was held under the deltoid muscle and axillary nerve, controlling it by palpation to prevent damage and then extraperiostally to the distal access wound (Fig. 3). Then, the distal end of the plate was found in the wound of distal access, oriented along the front surface of the humerus in the lower third of its diaphysis (Fig. 4), and the plate was fixed to the bone with several screws in the proximal and distal approaches.

At the next stage, precision preparation was performed on the used anatomical preparations, finding out the relationship of the plate established by the proposed method with large blood vessels and nerves. It was found that on all eight used preparations of the upper extremity, the plate was inserted between the axillary nerve and the humerus, preserving the specified nerve (Fig. 5), as well as the radial nerve and the deep artery of the shoulder with concomitant veins of the same name (Fig. 5). In addition, it was shown that this plate, installed in accordance with the proposed method, always passes at a certain safe distance from the musculocutaneous nerve (Fig. 6), as well as from the median nerve and brachial artery with a concomitant vein of the same name (Fig. 7 ) It should also be noted that on none of the eight preparations used, the plate was in contact with the tendon of the long head of the biceps of the shoulder, since its upper end was located in the area of proximal surgical access much lateral to the indicated anatomical formation.

Thus, the experiments performed on non-fixed anatomical material allowed us to conclude that the proposed technology of minimally invasive osteosynthesis with preoperative modeling of the plate avoids damage to the above important anatomical formations in the shoulder region.

The method is as follows.

Preoperative planning is carried out on the basis of standard radiography of the damaged shoulder in two projections and measurements of the length of the shoulder on the intact limb from the top of the large tubercle of the humerus to its lateral epicondyle. Moreover, for each particular patient, linear plates with angular stability of the screws and pointed ends with a length of 220 to 260 mm are selected depending on the length of the shoulder, the location and the extent of the fracture zone. Plate modeling is carried out on a proportional model of the right or left humerus, bending it in a spiral. At the same time, the upper end of the plate is located on the lateral surface of the humerus 1 cm below the top of its large tubercle and 1 cm lateral to the inter-tubercle groove, and the lower end of the plate on the front surface of the humerus is not lower than the level of its epicondyle.

During the operation, the patient’s position on the operating table is on the back with a raised head end. A damaged upper limb is laid along the body, the forearm is on average between the pronation and supination position, which provides the ability to visualize the humerus throughout along with fluoroscopic control. The operation involves: a surgeon, one assistant for auxiliary manipulations during the operation and one assistant for fluoroscopy. Treatment of the skin of the upper limb and limitation of the surgical field are carried out according to the generally accepted technique.

Projections of the following anatomical landmarks are noted on the skin of the injured limb: acromial and coracoid processes of the scapula, lateral epicondyle of the humerus. A skin incision line of the proximal access is outlined, starting from the lateral edge of the acromial process of the scapula and continuing distally by 3-5 cm towards the lateral epicondyle of the humerus. Next, a pre-modeled plate is applied to the skin of the shoulder, placing its proximal end 1 cm below the tip of the well-palpable large tubercle of the humerus. Then, a distal access skin incision line is plotted in the lower third of the shoulder along its front surface and along the midline, starting from the point defined by the lower edge of the modeled plate applied to the shoulder, and continuing by 3-5 cm in the proximal direction.

During the operation, first, an incision is made in the skin and subcutaneous adipose tissue along the designated line of proximal access. Next, the fibers of the deltoid muscle are bred stupidly between the front and middle portions of it. An axillary tunnel is then formed, sliding along the surface of the humerus with a simulated plate with angular stability of the screws having pointed ends. For the convenience of manipulating the plate, a drill guide for screws with angular stability, which is used as a handle, is inserted into one of its holes at the proximal end. To control the correctness of the formation of the channel, the index finger of the surgeon is introduced into it, facing the hind bone with its back surface. At the same time, the palmar surface of the nail phalanx of the index finger allows palpation of the axillary nerve, which is defined as a 3-4 mm thick strand located in the transverse direction with respect to the channel being formed.

It should be noted that the absence of an axillary nerve during palpation indicates incorrect (too superficial) channel formation and the risk of a nerve getting under the plate when it is implanted. In such cases, the plate is removed and a new axillary canal is formed closer to the humerus. After palpation of the axillary nerve, the formation of the axillary tunnel continues, sliding the plate along the periosteum from top to bottom with a gradual transition from lateral to the anterior surface of the humerus, conducting it over the fracture zone. During insertion, the assistant holds the injured limb in position of reposition of bone fragments by light traction and control of the neutral position of the forearm. The plate is considered to be fully inserted when its proximal end is located 1 cm distal to the tip of the large tubercle of the humerus and 1 cm lateral to the inter-tubercle groove.

Distal surgical approach 3-5 cm long is performed along the line previously planned on the skin of the shoulder. After an incision in the skin and subcutaneous adipose tissue, the biceps of the shoulder is retracted medially, and the brachial muscle is stratified longitudinally along the midline and spread apart. In this case, the distal end of the inserted plate is found in the wound.

Next, the proximal end of the inserted plate is temporarily fixed to the humerus with Kirschner spokes or a drill installed through the drill guide for screws with angular stability. The distal end of the plate is oriented in the wound along the front surface of the humerus in the lower third of its diaphysis. Then, bone fragments are repositioned under fluoroscopic control. At the same time, the axis, the length of the humerus are restored and the rotational displacement of bone fragments is eliminated.

Then the distal end of the plate is temporarily fixed to the bone with a drill through the drill guide for screws with angular stability. At this stage, it is still possible to correct the angular deformation of the humerus in the fracture zone if it is impossible to change its length and rotation of bone fragments. To improve the quality of reposition of bone fragments and / or fixation of intermediate bone fragments, it is possible to additionally use cortical screws, which are inserted through small incisions up to 1 cm long in the projection of the corresponding plate openings under fluoroscopic control.

After completion of the reposition of bone fragments, the plate is fixed to the humerus with screws with angular stability. At the same time, at least two such screws are installed in the proximal and distal parts of the plate, located respectively above and below the fracture zone. After locking the screws in the plate, the final fluoroscopic control of osteosynthesis in two projections is performed. Active drainages are installed in the area of proximal and distal surgical approaches. Produce layered suturing of surgical wounds.

In the postoperative period, immobilization of the operated upper limb with a scarf bandage is carried out for three weeks. Active movements in the shoulder and elbow joints begin from the second day of the postoperative period.

Clinical examples

1. Patient B., 54 years old, was admitted with a diagnosis of Closed comminuted fracture of the diaphysis of the left humerus with displacement of 12 B3 fragments according to the AO classification (Fig. 8). During preoperative planning, the shoulder length was determined, which was 35 cm from the top of the large tubercle of the humerus to its lateral epicondyle. Then they selected a model and simulated a plate with angular stability of 5.0 mm screws, 220 mm long and pointed ends. On the fifth day after the injury, an operation was performed: minimally invasive immersion osteosynthesis of the left humerus according to the proposed method (Fig. 9).

In the postoperative period, dysfunctions of the main vessels and nerves of the shoulder were not observed. The operated limb was immobilized with a scarf dressing for three weeks, and active movements in its joints were started from the second day after the operation. A control examination with radiographs and an assessment of the function of the upper limb was performed after 6 weeks (Fig. 10, 11). 14 weeks after the operation, distinct radiological signs of fracture fusion were observed (Fig. 12), as well as a good restoration of the function of the injured upper limb (Figs. 13, 14, 15).

2. Patient L., 20 years old, was injured as a result of an accident. Upon admission, a closed comminuted fragmentary diaphysis fracture of the left humerus 12 C1 was diagnosed according to AO classification, complicated by primary traumatic radial nerve neuropathy. During preoperative planning, the shoulder length (36 cm) was determined from the top of the large tubercle of the humerus to its lateral epicondyle. We chose a model and simulated a plate with angular stability of 5.0 mm screws, 260 mm long and pointed ends. On the third day after the injury, an operation was performed - minimally invasive immersion osteosynthesis of the left humerus according to the proposed method (Fig. 16).

After surgery, the operated upper limb was immobilized with a headscarf for three weeks. Active movements in the joints of this limb were allowed from the second day after surgery. Control examinations with radiographs and evaluation of limb function were performed 7 weeks after the operation of osteosynthesis (Fig. 17, 18). 12 weeks after the operation, radiological signs of fracture fusion were revealed (Figs. 19, 20), as well as a regression of neurological symptoms with a complete restoration of the function of the left upper limb.

Bibliography

1. Volgas D.A., Stannard J.P., Alonso J.E. Nonunions of the humerus // Clin. Orthop. Relat. Res. - 2004. - Vol. 419. - P. 46-50.

2. Rommens P.M., Blum J., Runkel M. Retrograde nailing of humeral shaft fractures // Clin. Orthop. - 1998. - Vol. 35, No. 1. - Ρ 26-39.

3. Zhiquan, Α., Bingfang. Z., Yeming. W., Chi Z., Peiyan H. Minimally invasive plating osteosynthesis (MIPO) of middle and distal third humeral shaft fractures // J. Orthop. Trauma. - 2007. - Vol. 21 No. 9 - P. 628-633.

4. Shin S.J., Sohn H.S., Do N.H. Minimally invasive plate osteosynthesis of humeral shaft fractures: a technique to aid fracture reduction and minimize complications // J. Orthop. Trauma. - 2012. - Vol. 26, No. 10. - P. 585-589.

5. Canale S.T., Beaty J.H. Campbell’s Operative Orthopedics. - 12th ed. - Elsevier Mosby. - 2013 .-- P. 2852-2862.

6. Castoldi F., Blonna D., Assom M. Simple and complex fractures of thehumerus - Springer, Italia, 2015 - P. 213-248.

7. Blum J., Janzing H., Gahr R., et al. Clinical performance of a new medullary humeral nail: antegrade versus retrograde insertion // J. Orthop. Trauma. - 2001. - Vol. 15. - P. 342-349.

8. Jojua A.B. Retrograde osteosynthesis of the femur and humerus // Bulletin of the National Medical and Surgical Center named after N.I. Pirogov - 2008. - T. 3, No. 2. - S. 25-27.

9. Livani B., Belangero W. D. Bridging plate osteosynthesis of humeral shaft fractures // Injury. - 2004. - Vol. 35. - P. 587-595.

10. Fernandez Dell′Oca A.A. The principle of helical implants. Unusual ideas worth considering. Case studies // Injury - 2002 - Vol. 33, Suppl 1: SA - P. 29-40.

11. Ming Y., Baoguou J., Dianying Zh. CN102551863 (B) .- Anatomicalhumerus bridge-type bone fracture plate // http: //worldwide-i.espacenet.com/ 2015.

Claims (1)

A method of minimally invasive bone osteosynthesis in case of fractures of the diaphysis and surgical neck of the humerus, comprising holding a spiral curved plate with angular stability of the screws and pointed ends into the channel formed under the shoulder muscles and reposition of bone fragments with their subsequent fixation, characterized in that they model a linear plate of the selected length depending on the nature and location of the fracture, bending it according to the model of the humerus, commensurate with the damaged bone of the patient, then in accordance and with the location of the ends of the simulated plate on the patient’s shoulder, the landmarks and projections of the proximal and distal surgical approaches are plotted on the skin, then the plate is inserted intraoperatively from the proximal access under the deltoid muscle and axillary nerve, controlling it by palpation to prevent damage, and then extraperiostally above the fracture zone, then visualize the distal end of the plate in the wound and orient it along the front surface of the humerus in the lower third of its diaphysis, after which dissolved definitive reduction and fixation of bone fragments.

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