RU2627290C1 - Method for correction of combined flexion contracture of three-phalangeal fingers and forearm pronation contracture - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: tendons of the superficial and deep finger flexors are intersected, followed by the movement of distal ends of the tendons of the deep finger flexor to the proximal ends of the tendons of the superficial flexor with elongation. Tendons of the superficial finger flexor are cut off at the level of main phalanges, and the tendons of the deep finger flexor - 1 cm proximally to the wrist canal origin. The proximal ends of the tendons of the deep finger flexor are transposed in the subcutaneous tunnel through the ulnar side to the rear forearm and fixed to the distal metaepiphysis of the radius at the place where the brachial muscle tendon is attached, to obtain active supination, and the distal endsof the superficial flexor tendon are used to form the tenodes of proximal interphalangeal joints of II-V fingers.

EFFECT: method allows to strengthen active supination, prevent hyperextension in proximal interphalangeal joints.

10 dwg

Description

The invention relates to medicine, neurosurgery, neurology, plastic surgery, as well as orthopedics and can be used for surgical correction of combined contractures of the three-phalangeal fingers and forearm, accompanied by shortening of the muscles of the flexors of the three-phalangeal fingers and forearm pronators. Such a pathology occurs with spastic lesions of the upper limb, ischemic contracture (Volkman), arthrogryposis.

Mild deformations can be corrected by conservative orthopedics, for example, using splinting, spiral piercing tutors, or therapeutic methods (e.g. botulinum therapy) (1).

Surgical intervention is necessary to correct moderate to severe deformities.

The problem of isolated flexion contracture of the three-phalangeal fingers is resolved. With moderate shortening of the muscles of the flexors of the three-phalangeal fingers, their fractional lengthening is possible, suggesting that the incisions are made at the places of transition of these muscles to the tendons (2). In addition, mobilizing operations can be performed to reduce pathological muscle traction: detach muscles from the apophyses of bones or displace them together with the fixation point distally and cut off the tendons from the point of attachment (the so-called muscle slides and releases).

With severe deformities, a more significant lengthening of the muscles or tendons is necessary. For this purpose, various versions of tendon-muscle transpositions and their combinations are used (3). The greatest lengthening of the flexor tendons of the three-phalangeal fingers is achieved by the Epstein-Rozov operation (superficialis to profundus procedure). In this case, after crossing the tendons of the superficial flexor proximal to the beginning of the carpal canal, and the tendons of the deep flexor at the place of transition of the tendon to the muscle, the distal ends of the tendons of the deep flexor of the three phalangeal fingers are transposed to the proximal ends of the tendons of the surface flexor of the three phalangeal fingers (4, 5).

Various options have also been described to eliminate isolated pronational pronature contracture. In severe pronation contractures, corrective osteotomy of the forearm bones is possible (6) and even arthrodesis of the wrist joint with correction of the rotation of the forearm and hand (7). However, if the passive rotation of the forearm is preserved, more often preference is given to the restoration of active supination. The release (tenotomy) of the round pronator leads to an improvement in active supination (8). It is possible to reduce the pathological tone of the round pronator with partial preservation of its function: by performing selective motor neurotomy (9), and to enhance supination, the round pronator is transposed to the supine position. This procedure can be performed by cutting off the tendon, passing it through the interosseous membrane around the radius, followed by fixation to the latter, as in the case of the Tubey operation (Fig. 5) (10).

It is possible to move the tendon without clipping. To do this, perform a radius osteotomy and transfer the tendon to the rear of the radius through the interval between the fragments (Fig. 6) (10), then perform the osteosynthesis of the radius.

However, in this category of patients, situations often arise when the muscles lose their contractility. This condition is also possible for a round pronator, which makes it impossible to use it to enhance supination. In addition, such an application of the round pronator is complicated by the fact that after moving it will perform the function opposite to the nominal (familiar) one, and retraining a new skill will be a very difficult task. Clinical situations are also possible when, according to the plan, with multiple transpositions, the round pronator can be used to form other movements, for example, extension of the hand.

In view of the foregoing, other variants of muscle transpositions were proposed for the formation of active supination, for example, the movement of the tendon of the brachioradialis muscle allows achieving a good supination effect (11, 12). No less popular technique proposed by Green D.P. in 1942 (Green's transfer) (Fig. 7) (13, 14). It allows you to achieve a significant increase in active supination according to biomechanical studies. (fifteen). This pronounced effect is connected, apparently, with the successful direction of the traction force vector, as well as with a good excursion (traction) of the ulnar flexor of the hand in comparison with a round pronator. Another variant of transposition of the ulnar flexor of the wrist is described, in which the entire strength of the muscle unit is directed only to supination of the forearm (Fig. 8) (16). The author proposes to connect the distal end of the tendon of the ulnar flexor of the wrist (FCU) to the radial bone with fixation to the flank of the tendon of the shoulder-radial muscle.

This method is the closest in essence to the proposed method.

However, it only solves the problem of creating active supination while eliminating pronational contracture, which is most often only part of the combination, which also includes the flexion contracture of the three-phalangeal fingers. We consider the solution to the problem of combined contracture, including pronation of the forearm and flexion of the three-phalangeal fingers by simultaneously performing the above procedures (Epstein-Rozov Operation and transposing the FCU to the radius), due to the uneconomical use of muscle units.

The objective of this invention is to develop methods for the operative correction of combined contracture, including a pathological flexor installation of the three-phalangeal fingers and a pronational installation of the forearm, which would achieve a significant lengthening of the tendons of the flexors of the fingers, with the formation of supine muscle traction on the forearm with the most economical and biomechanically beneficial use of motor units.

The technical result of this invention is to increase the effectiveness of surgical treatment of combined flexor contracture of the fingers and pronational contracture of the forearm due to the implementation of the following positions:

- a significant lengthening of the flexor tendons of the II-V fingers;

- strength-enhancing active supination;

- preservation during transposition of “popular” muscle donors for reserve;

- prevention of hyperextension in the proximal interphalangeal joints of the II-V fingers of the hand.

The result is achieved by performing:

• intersections of the tendons of the superficial flexor of the three-phalangeal fingers of the hand at the level of the main phalanges, and the tendons of the deep flexor of the three-phalangeal fingers of the hand at the level of the forearm;

транспозиции дистальных концов сухожилий глубокого сгибателя трехаланговых пальцев кисти с удлинением на проксимальные концы сухожилий поверхностного сгибателя пальцев;

transposition of the distal ends of the tendons of the deep flexor of the triangangal fingers with an extension to the proximal ends of the tendons of the superficial flexor of the fingers;

транспозиции на тыльно-лучевую поверхность лучевой кости проксимальных концов сухожилий глубокого сгибателя пальцев. При этом возможно использование в зависимости от необходимой мощности супинационного усилия одного, двух, трех или всех четырех брюшек мышцы-донора (глубокого сгибателя II-V пальцев);

transposition on the dorsum-radial surface of the radius of the proximal ends of the tendons of the deep flexor of the fingers. It is possible to use, depending on the required power, the supination force of one, two, three or all four abdomen of the donor muscle (deep flexor II-V fingers);

использования дистальных концов сухожилий поверхностного сгибателя пальцев кисти для тенодеза проксимальных межфаланговых суставов пальцев кисти, препятствующего переразгибанию данных суставов.

the use of the distal ends of the tendons of the superficial flexor of the fingers for tenodesis of the proximal interphalangeal joints of the fingers of the hand, which prevents over-extension of these joints.

The drawings show:

FIG. 1-3 - A correction method for combined flexion contracture of the fingers of the hand and pronational contracture of the forearm:

position 1 - the distal ends of the tendons of the deep flexor of the fingers;

position 2 - legs of the superficial flexor of the fingers (tenodesis of the proximal interphalangeal joints of the fingers);

position 3 - the proximal ends of the tendons of the superficial flexor of the fingers (near the suture with the tendons of the deep flexor);

position 4 - the proximal end of the tendon of the deep flexor of the fingers;

position 5 - muscle abdomen of the deep flexor of the fingers;

position 6 - muscle abdomen of the superficial flexor of the fingers;

position 7 - the place of fixation of the end of the tendon of the deep flexor of the fingers.

FIG. 4 - The location of the circular pronator on the forearm is normal.

FIG. 5 - Displaced circular pronator of the forearm.

FIG. 6 - A method for the correction of pronational contracture is the movement of the circular pronator of the forearm after osteotomy of the radius.

FIG. 7 - Method for correction of pronation-flexion contracture.

Transposition of the ulnar flexor of the wrist onto the short radial extensor of the hand:

FCU - ulnar flexor of the wrist;

ECRL - long radial extensor of the wrist;

ECRB is a short radial extensor of the wrist.

FIG. 8 - Method of correction of pronational contracture, transposition of the ulnar flexor of the wrist on the radius, with fixation on the tendon splinter of the brachioradialis muscle.

FIG. 9 - Appearance of the upper limb with combined flexion contracture (clinical example: patient K., 28 years old, with left-sided spastic hemiparesis as a result of traumatic brain injury (TBI)).

FIG. 10 - Appearance of the limb at 9 weeks after surgery (clinical example: patient K., 28 years old, with left-sided spastic hemiparesis as a result of head injury).

The method is as follows (Fig. 1).

A curly cut along the palmar surface of the forearm provides access to the flexor tendons throughout the forearm, and identifies them. Through accesses along neutral lines on the main phalanges, the tendons of the superficial flexor are cut to the II-V fingers. The remains of these legs are fixed to the main phalanx with the formation of tenodesis in the extension position of 180 °, which helps to prevent over extension in the proximal interphalangeal joints (Fig. 1, 3, position 2). Fixation can be performed using anchors or a transossal suture. Tendons of the superficial flexor are removed to the wound on the forearm and taken to the side. Tendons of the deep flexor (Fig. 1, 2, position 1) are cut off at a place 1 cm proximal to the beginning of the wrist channel (canalis carpi) in the extension position of the fingers and hand. Thus, the maximum length of the tendons on the remaining abdomen of the deep flexor is achieved. Then the tendon of the round pronator is cut off from the attachment to the radius. If the mobilization performed is not enough, an additional square pronator slide is performed. The forearm is brought to the supination position and fixed with the Kirschner needle.

A channel is formed to the point of attachment of the brachioradialis muscle: in the subcutaneous tissue with a blunt surgical instrument (bougie or clamp) pass through the medial, dorsal and then on the lateral sides of the forearm to the distal metaepiphysis of the radius to the place of attachment of the brachioradialis muscle. Having prepared the "bone bed", draw through it and hem the proximal end (Fig. 1, 2 position 4) of the deep flexor tendon (Fig. 1, 2, position 5) in light tension. Fixation can be carried out by conducting a tendon through a drilled channel in the distal radial metaphysis of the radius and the suture of the loop of the tendon "on yourself" (Fig. 1, 2, position 7), transossal suture or anchor fixation.

If possible, the brush and fingers are brought to a physiological position. If necessary, they extend the wrist flexors (fractionally, z-shaped or using tendon grafts) or they are cut off from the attachment point, in cases when their transposition is planned, or there is no active control of these muscles. In the physiological position, the optimal length of the tendons of the superficial flexor of the fingers is selected (Fig. 1, 2, position 6) and their excess is cut off. Then, the distal ends of the deep flexor tendons are sutured to the proximal ends of the superficial flexor (Fig. 1, 2, position 3), as during the Epstein-Rozov operation (3, 4).

In cases of a combination of surgery with other transpositions, for example, on the extensors of the fingers, or lengthening of the flexors of the wrist, donor muscles are extracted when working with the flexors, and they are sutured after the extensors of the hand, but before the seam on the flexors of the fingers.

With excessive deep flexion traction, it is possible to connect not all muscle abdomens, but depending on balance and tone, in various combinations: one, two, three, four abdomen. In this case, preference is given to the most medially located muscle abdomen. That is, in order of preference: the flexor of the V, IV, III, II fingers. The remaining muscle abdomen, if necessary, can be used for other transpositions.

When using several muscle abdomens, the distal ends stitch them together, choose the most powerful (thick) tendon, which is saved, and the rest are cut off.

Control hemostasis and suture skin wounds. Immobilization is done with a plaster cast on the shoulder-forearm-wrist-fingers on the back surface. Position: flexion 90 ° in the elbow joint, neutral position of the hand - 0 °, flexion in the metacarpophalangeal joints of II-V rays 120 °, extension of the interphalangeal joints 180 °. In this case, the fingers in the bandage are not fixed. Thus, there remains the possibility of flexion in the metacarpophalangeal joints from 120 ° to full flexion, in interphalangeal joints from 180 ° to full flexion. The forearm is fixed with a needle in the supination position. After 3 weeks, the span can be replaced with a support bandage that lasts up to 8 weeks. The needle is removed 8 weeks after surgery.

The advantage of this method is that the presence of four separate muscle abdomen in the muscle of the donor (deep flexor II-V fingers) allows you to calibrate the strength of the connected motor units. The most widely used donor muscles (ulnar flexor of the wrist, radial flexor of the wrist, shoulder-beam muscle, round pronator) remain intact for the possibility of using them for other transpositions.

This technique was applied in the surgical treatment of patient K., 28 years old, with combined contracture of the upper limb that arose against the background of spastic left-side hemiparesis due to traumatic brain injury. The patient had pronational forearm contracture, flexion contracture of the wrist joint and fingers, resulting in contracture of the first ray. The patient does not use her hand, as she cannot open her fist and bring the brush to grip (Fig. 9).

During the operation, the release of the round pronator, the fractional lengthening of the radial flexor of the wrist, the z-shaped tendon of the long flexor of the I finger of the hand, the extension of the flexors of the three-phalangeal fingers by transplanting the tendons of the deep flexor onto the muscles of the superficial flexor of the fingers, the transposition of the ulnar flexor of the fingers with the connection to the tendons of the common extensor were performed of the long palmar muscle to the tendon of the long muscle abducing the first finger and the transposition of the deep flexor to the II-V fingers on the distal met radius epiphysis in the position of supination. A satisfactory immediate result has been achieved. The patient can independently actively extend her fingers, supine the forearm, and divert the first finger. Removing the hand from a vicious position allowed the patient to use it for simple grips in everyday life (Fig. 10).

References

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Claims (1)

A method of surgical correction of combined flexor contracture of three phalangeal fingers and pronation of the forearm, including the intersection of the tendons of the superficial and deep flexors of the fingers, the movement of the distal ends of the tendons of the deep flexor of the fingers to the proximal ends of the tendons of the superficial flexor with elongation, characterized in that the tendons of the superficial flexor of the fingers are cut off at the main phalanges, and the tendons of the deep flexor of the fingers - 1 cm proximal to the beginning of of the wrist, then the proximal ends of the tendons of the deep flexor of the fingers are transposed in the subcutaneous tunnel through the ulnar side to the rear of the forearm and fixed to the distal radial metaepiphysis at the site of attachment of the brachialis tendon to receive active supination, and the distal ends of the tendons form the surface of the flexor tenodesis of the proximal interphalangeal joints of the II-V fingers.

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