RU2605148C1 - Diagnostic technique for radiopaque foreign bodies in soft tissues of human - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery and traumatology, and can be used for non-invasive diagnostic of radiopaque foreign bodies in soft tissues of human being. At first stage of examination ultrasound examination of problem area is performed. At second stage after selection of modelling size and hard non-invasive fixation of copper mesh to skin with adhesive patch in projection of foreign body localisation X-ray examination in one non-standard projection is made. Screen of copper wire with section 0.5 mm is used. Size of cells is 1×1 cm, right lower corner cell has dimensions of 1×2 cm. At third stage contours of copper mesh limits and abnormal cell of 1×2 cm are applied to skin with marker. Shadow of cell containing shadow of foreign body is found at X-ray image. On basis of obtained data specified square of mesh, attached to skin, is determined, within which accurate projection of foreign body is applied to skin with marker.

EFFECT: method enables high-accuracy determination of localisation of radiopaque foreign body in soft tissues.

1 cl, 15 dwg, 4 tbl, 4 ex

Description

The invention relates to surgery and traumatology and can be used for non-invasive determination of the localization of radiopaque foreign bodies in human soft tissues with a view to their subsequent removal.

The existing interest in foreign bodies of soft tissues is due to the widespread occurrence of this phenomenon not only as a consequence of trauma, but also as a result of unintentional abandonment of drainage tubes, catheters, metal fragments in the field of surgical intervention (Koren M.N. et al., 2012; Mamedov A. A. et al., 2013; Dean AJ, 2011). In addition, there is a special group of patients who independently introduce various foreign bodies into the soft tissues (Alyabyev F.V. et al., 2008; Kafaween N.M. et al., 2010; Dhatariya K. Et al., 2012). According to a number of authors, in 12-38% of patients the injury is complicated by the ingress of various foreign bodies into the wound (Anokhin A.A., 2005; Crystal C.S. et al., 2009). About 40% of foreign bodies are X-ray negative (Chulovskaya I.G. et al., 2008; Turkcuer I. et al., 2006). The proportion of unsuccessful deletions is 12.5-30% (Mamedov A.G., 1984; Dean A.J., 2011). Of particular difficulty is the detection and removal of small and deeply located foreign bodies in soft tissues. Often, even with radiopaque foreign bodies, in order to clarify their localization, there is a need for the consistent use of additional instrumental research methods: ultrasound, CT, MRI. In this regard, there is a constant search for new techniques and devices that facilitate the search for foreign bodies: magnets, tags, radio probes, etc. (Mamedov A.G., 1985; Dean A.J., 2011). According to a number of researchers, the search for a foreign body requires a lot of time, leads to extensive tissue damage, and also creates a risk of complications (Gooding G.A. et al., 1987; Dean A.J., 2011).

The aforesaid necessitates a more detailed development of both a comprehensive diagnosis of foreign bodies and methods of planning for online access. In addition, timely diagnosis and removal of foreign bodies allows you to avoid complications in the form of surgical infection of soft tissues, fistulas, impaired limb function, chronic pain syndrome.

Prototypes are known where the authors use non-invasive techniques for diagnosing the location of a foreign body (Patent SU 1009424, Khanin M.Yu. et al., 1972; Patent SU 643146, Yurchak V.F. et al., 1979). These devices and devices have significant drawbacks consisting in the complex multicomponent design of the proposed devices, which exist only in the form of prototypes, the impossibility of their manufacture without special equipment, multi-stage methods, which leads to a significant waste of time, the need for applying a plaster cast and sawing windows in it, which reduces the mobility of the patient. In addition, when conducting an X-ray examination, the presence of a doctor is necessary to monitor the position of the device.

Known methods are where the authors use invasive techniques to determine the location of a foreign body, involving the introduction of graduated metal needles, knitting needles, rods into the body tissue during the diagnostic process (Patent SU 1602455, D. Gevko et al., 1987). A significant drawback of this technique is additional trauma, impaired ability of the patient to move independently, which creates the need for transportation to the X-ray room with unfixed needles inserted into the tissue, causing pain and creating a risk of damage to vital formations. Application of the method is limited in case of paraossal localization of foreign bodies.

Known methods where the authors propose to introduce dye to a foreign body after marking its location with needles (Patent SU 1602455, Gevko DI et al., 1987) or dye is injected into the wound canal (Patent RU 2313294, Ashmarin OM et al. ., 2007). Of course, the introduction of dye is valuable only with "fresh" injuries and wide wound channels. However, if the wound channel is narrow, for example, after an injury with a sewing needle, it is not possible to inject dye into it, and foreign bodies that are in soft tissues for a long time are encapsulated and the dye does not mark them. In addition, aniline dyes are toxic and can lead to tissue necrosis.

A known method of determining the location of a foreign body in the soft tissues of a person, the description of which is attached in other materials (Koren M.N. Method and device for removing radiopaque foreign bodies in the practice of a traumatologist [Text] / M.N. Koren, A.P. Bespalchuk, VN Gurko // Medical journal. - 2012. - No. 1. - P. 123-124), which consists in sequential radiography in a lateral projection to determine the depth of a foreign body and radiography in direct projection after suturing to the skin with metal ligatures re etki. Then, the square in which the foreign body is projected radiologically is determined.

However, the technique of using the device has a number of significant drawbacks that reduce its effectiveness. Firstly, x-ray performed in a lateral projection does not give an accurate idea of the depth of a foreign body in soft tissues. Secondly, the authors do not consider the need to use grids of various sizes depending on the characteristics of the anatomical region in which the foreign body is localized. Thirdly, the rigidity of the lattice does not allow simulating it before fixing in accordance with the configuration of a particular area of the body. Fourth, the invasive fixation of the lattice necessitates its mandatory sterilization before use. Fifth, X-ray analysis with a metal mesh in a direct standard projection prevents the choice of the most rational online access. Sixth, before performing the study, the lattice is fixed to the skin with ligatures, which leads to additional trauma and creates discomfort for the patient. Seventh, after radiography, the projection of a foreign body is not applied to the skin with a permanent indelible marker.

All the above methods for the topical diagnosis of radiopaque foreign bodies of soft tissues do not have a phased approach and do not take into account a number of nuances, namely:

1. The need for consistent use in a comprehensive non-invasive diagnosis of X-ray contrasting foreign bodies of soft tissues with ultrasound and technically simple devices, taking into account the real capabilities and equipment of domestic medical institutions;

2. The need for individual selection of the size of the wire mesh, depending on the anatomical region in which the foreign body is localized;

3. The possibility of modeling the grid in accordance with the configuration of a specific area of the body;

4. Possibilities of non-invasive fixation of the mesh to the skin using strips of sticky patch in the projection of localization of a foreign body;

5. The need to perform radiography with a copper mesh in one direct non-standard projection, taking into account the direction of future operational access;

6. The need for applying to the skin with a permanent indelible marker of the projection of a foreign body in accordance with the mesh cells.

The objective of the invention is to develop a method for the diagnosis of radiopaque foreign bodies in human soft tissues, regardless of their location, devoid of the above disadvantages.

The technical result consists in the fact that the most accurate topical diagnosis of an X-ray contrast foreign body in the soft tissues of the human body is carried out using complex instrumental diagnostics using non-invasive techniques and technically simple devices in the form of a copper mesh.

The technical result is achieved as follows. To detect a radiopaque foreign body in soft tissues and determine its exact projection onto the body surface, we have proposed an algorithm for examining a patient, which includes several stages.

At the first stage, to determine the depth of the foreign body and its relationship with the anatomical formations of a particular area of the body, ultrasound of soft tissues is performed. The study is carried out using a multi-purpose ultrasound scanner in real time using high-frequency linear sensors at 7.5-12 MHz. On the monitor screen, foreign bodies look like objects of uniform structure with high acoustic density and acoustic shadow, as shown in FIG. 8 and FIG. 13.

At the second stage, a device is used for non-invasive precision topical diagnosis of X-ray contrast foreign bodies in human soft tissues, described in the application for the invention "A device for non-invasive precision topical diagnosis of X-ray contrast foreign bodies in human soft tissues", authors: A. Koval, G. Melkonyan G., Romanov V.E., Koval O.A., Tashkinov N.V., Strelnikova N.V., sent to FIPS on 06/18/2015, in the form of a mesh made of copper wire with a cross section of 0.5 mm, with cells 1 × 1 cm, lower right corner I cell of which has an excellent size of 1 × 2 cm, which is shown in FIG. 1. The size of the copper mesh is selected depending on the anatomical region in which the foreign body is localized. So, for the fingers of the hand and foot, a grid of 2 × 5 cm is used, for the brush - 5 × 5 cm in size, which is shown in FIG. 2. For the gluteal region, limbs, and with multiple foreign bodies - 10 × 10 and 10 × 20 cm in size, which is also shown in FIG. 2. The device is then modeled in accordance with the configuration of a specific area of the body, as shown in FIG. 3, and is firmly fixed to the skin using strips of sticky patch, as shown in FIG. 4. If there are wounds in the projection of the alleged location of a foreign body, the copper mesh is pre-sterilized in an autoclave or a dry heat cabinet. If urgent research is necessary, if the mesh is not sterile, the wound is sealed with a transparent sterile coating “Kruosorb” of CJSC “Meditek” Russia, on top of which the device is fixed.

At the third stage, on a stationary X-ray apparatus, an X-ray is taken of a body area with a fixed copper grid in one direct non-standard projection. After performing an X-ray examination and obtaining an image, the border of the copper mesh and a non-standard cell 1 × 2 cm is drawn around the contour with an indelible marker, as shown in FIG. 5 and FIG. 6. Then, guided by the x-ray, find the shadow of the cell containing the shadow of a foreign body, and calculate the number of squares in the vertical and horizontal rows from this cell to the edge of the grid. Further, guided by the data obtained, at the intersection of the vertical and horizontal rows of squares of the grid located on the skin, the desired cell is determined and an exact projection onto the skin of foreign bodies is applied with a marker, as shown in FIG. 7. Markings applied with a marker practically do not wash off the skin with antiseptics in preparing the surgical field. After use, the copper mesh is disinfected in a standard manner, like any general surgical instruments.

At the next stage, taking into account the data obtained, surgical removal of a foreign body is performed.

The advantages of the proposed method of non-invasive precision topical diagnosis of radiopaque foreign bodies in human soft tissues are as follows:

1. The use of a complex of non-invasive precision diagnosis of a foreign body in the soft tissues of ultrasound, which gives the most accurate idea of the depth and topographic relationship of a foreign body to neighboring anatomical formations;

2. The size of the copper mesh is selected depending on the anatomical region in which the foreign body is localized;

3. Preliminary modeling of the copper mesh in accordance with the configuration of a particular area of the body ensures its tight fit to the surface of the skin;

4. The copper mesh is non-invasively fixed to the skin using strips of sticky patch in the projection of localization of a foreign body;

5. In the absence of wounds in the projection of the alleged location of a foreign body, there is no need for mandatory sterilization of the copper mesh;

6. If there are wounds in the projection of a foreign body, the study can be performed with either a sterile or non-sterile mesh, after preliminary closure of the wound with a transparent sterile Kruosorb coating;

7. Radiography with a copper mesh is performed in only one direct non-standard projection, taking into account the localization of future operational access, which reduces radiation exposure;

8. Radiography data allow you to calculate with maximum accuracy the cell into which the shadow of a foreign body is projected and apply its exact projection onto the skin with a marker.

In view of the need to evaluate the effectiveness of the proposed diagnostic methodology, we found that during the period from 1985 to 2014, 125 patients with radiopaque foreign bodies in soft tissues were treated in the departments of purulent surgery and traumatology 301 in Khabarovsk.

The traditional method for the diagnosis of radiopaque foreign bodies of soft tissues was used from 1985 to 2001 in 82 (65.6%) patients of the control group and did not provide for comprehensive diagnostics using ultrasound and a copper mesh. The proposed method for non-invasive diagnosis of radiopaque foreign bodies in soft tissues in the period from 2002 to 2014 and was used in 43 (34.4%) patients of the main group.

The formed groups were similar by sex, age, duration of the disease, the number of previous operations (t <2; p> 0.05), which made it possible to objectively justify the reliability of the results.

The age of patients ranged from 16 to 55 years, averaging 25.9 ± 3.2 years in the main group and 23.7 ± 2.6 years in the control group. In both groups of men there were 123 (98.4%), women - 2 (1.6%).

By the time of stay of foreign bodies in soft tissues at the time of hospitalization, patients were divided as follows: 75 (60%) patients were admitted in the first 7 days from the moment of injury, 21 (16.8%) - up to 1 month, 12 (9.6% ) - up to 6 months, 9 (7.2%) - up to a year, 8 (6.4%) - after a year or more, which is presented in table 1.

Most often, soft needles identified sewing needles and their fragments in 85 (68%) cases. In addition, various metal fragments were diagnosed in 19 (15.2%) cases, glass fragments in 14 (11.2%), metal wire fragments were detected in 4 (3.2%), and in 3 (2.4 %) cases, objects from radiopaque plastic are found, which are presented in table 2.

Most often - 39 (30.2%) cases - foreign bodies were localized in the tissues of the foot, in 32 (25.6%) cases, foreign bodies were localized in the lower leg. Foreign bodies were found in the brush in 27 (21.6%) cases, in the thigh in 17 (13.6%) and in the gluteal region in 10 (8%) cases, which are presented in table 3.

All foreign bodies in patients of the main group were removed during the first operation, while in patients of the control group successful extraction during the first operation was only 68 (82.9%), while in 23 (28%) patients thereafter several surgical interventions were performed. The frequency of operations performed per patient was 1.51. In 5 (6.1%) patients of the control group, foreign bodies, despite repeated operations, were not removed.

The duration of surgery in patients of the control group averaged 45.8 ± 0.8 minutes, while the duration of surgery in patients of the main group, due to the exact topical diagnosis of foreign bodies, was 20.6 ± 0.3 minutes.

In 6 (7.3%) patients of the control group, suppuration of postoperative wounds was diagnosed, which is associated with the duration of the operation and tissue trauma, while in the patients of the main group there were no such complications. The advantages associated with the application of the proposed diagnostic method are reflected in table 4.

Thus, the proposed method is highly effective and can be successfully used in patients with radiopaque foreign bodies of soft tissues.

The effectiveness of the proposed method for the diagnosis of foreign bodies is illustrated by clinical examples.

Example 1

Patient B., 19 years old, was admitted to the purulent surgery department on 02/11/2014 with a diagnosis of a foreign body - a sewing needle - in the soft tissues of the right hand. Complaints of pain on the right hand during movements. The words. 12/16/2013, he cleaned the table with the palm of his hand, felt a stitching pain in his hand. I independently extracted the part of the needle that protruded above the skin. The injection mark healed quickly. In view of the constant stitching pains in the hand, he turned to the MP unit. Radiography was performed, a foreign body was revealed in the soft tissues of the palmar surface of the right hand. Hospitalized in 301 VKG. There are no inflammatory infiltrates on the palmar surface of the right hand. On the presented X-ray diffraction patterns, in the soft tissues of the hand there is a foreign body - a piece of a sewing needle 1.5 cm long. After determining the depth of a foreign body using ultrasound, as indicated by arrow 1 in FIG. 8 and an X-ray projection of a foreign body using a copper mesh as shown in FIG. 9, an exact projection of a foreign body with a marker is applied to the skin, as shown in FIG. 10. On February 13, 2014, a foreign body, shown in FIG. 11. During the control x-ray, there is no foreign body in the soft tissues of the right hand. The wound healed by primary intention.

Example 2

Patient O. 19 years old, was admitted to the Department of Purulent Surgery 02.09.2009, with a diagnosis of a foreign body of the soft tissues of the left thigh. Complaints of stinging pain when walking in the left lower leg. According to the words, in May 2009, while cleaning the house, I felt a stitching pain in my left leg, noted that part of the needle protrudes above the surface of the skin and removed it myself. On the day of the injury, he turned to the emergency room. Radiography was performed, a fragment of the sewing needle was found in the soft tissues of the left lower leg, however, no attempts were made to remove the foreign body, the patient was told that it was impossible to remove the foreign body. Periodically, aching pains, redness of the skin occurred in the projection of the localization of the needle. After being drafted into the army, against the background of increased physical exertion, he noted increased pain in the area of the foreign body. Sent to 301 VKG. On radiographs of the left lower leg in the upper third in soft tissues, a foreign body of metallic density is determined paraossally. After determining the depth of the foreign body using ultrasound, as shown in FIG. 12, and determining a radiological projection of a foreign body using a metal mesh, as shown in FIG. 13, an exact projection of a foreign body, as shown in FIG. 14. January 29, 2014, under local anesthesia, the foreign body shown in FIG. 15. The needle was encapsulated in tissues, corroded. During the control x-ray, there is no foreign body in the soft tissues of the right lower leg. The wound healed by primary intention.

Example 3

Patient O. 20 years old, was admitted to the trauma unit 05.01.2000, with a diagnosis of a foreign body of the soft tissues of the left thigh. Complaints of admission to periodic pain while walking in the left thigh. According to him, on January 4, 2000, in order to avoid military service, he introduced a sewing needle into his left thigh. On the day of self-harm, he turned to the medical unit of the unit. Radiography was performed, a sewing needle was found in the soft tissues of the left thigh. An unsuccessful attempt was made to remove a foreign body. Sent to 301 VKG. On radiographs of the left thigh in the middle third in the soft tissues, a linear foreign body of metal density is determined. On January 6, 2000, under local anesthesia and on January 9, 2000, under anesthesia, attempts were made to remove a foreign body, which were unsuccessful. Due to suppuration of a postoperative wound, on January 11, 2000, the patient was transferred to the purulent surgery department. As a result of the treatment, the inflammation in the wound died down. After determining the depth of the foreign body using ultrasound and determining the x-ray projection of the foreign body using a metal mesh, the exact projection of the foreign body is applied to the skin. On January 17, 2000, a foreign body was discovered and removed under local anesthesia. The primary suture of the wound. Primary healing.

Example 4

Patient B., 54 years old, was admitted to the purulent surgery department on 06/09/2003 with a diagnosis of a foreign body of soft tissues of the right lower leg. Complaints on admission to pain in the right lower leg. According to him, on 05.06.2003, when working with metal, when struck with a hammer, a fragment of a metal part pierced clothes at high speed and penetrated into the soft tissues of the right lower leg. On the day of the injury, he turned to the trauma center. Radiography was performed, in the soft tissues of the right lower leg, a high-intensity triangular shadow of 0.8 × 0.2-0.4 cm is determined on the outer surface. An unsuccessful attempt was made to remove a foreign body, the wound was sutured. Due to suppuration of the postoperative wound, the patient was hospitalized in the purulent surgery department. As a result of the treatment, the purulent-inflammatory process in the wound was stopped. After determining the depth of the foreign body using ultrasound and determining the x-ray projection of the foreign body using a metal mesh, the exact projection of the foreign body is applied to the skin. 06/15/2003, under local anesthesia, a foreign body was discovered and removed. The wound is sutured. Primary healing.

Claims (1)

A method for non-invasive diagnosis of radiopaque foreign bodies in human soft tissues, including an x-ray examination using a metal mesh fixed to the skin with 1 × 1 cm cells, characterized in that they use a mesh made of 0.5 mm copper wire with a lower right corner cell measuring 1 × 2 cm; at the first stage of the study, an ultrasound of the problem area is performed, at the second stage, after selecting the size, modeling and tight non-invasive fixation of the copper mesh to the skin with an adhesive patch in the projection of localization of a foreign body, an X-ray examination is performed in one non-standard projection, at the third stage, the contours of the borders are applied with an indelible marker to the skin copper mesh and a non-standard cell 1 × 2 cm, then on the roentgenogram find the shadow of the cell containing the shadow of a foreign body, and on the basis of the data obtained, determine the the square of the mesh attached to the skin, within which a marker is applied to the projection onto the skin of a foreign body.

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