RU2648862C2 - Method for correcting combined flexural contracture of the hand and three-phalanx fingers in spastic paralysis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to neurosurgery, orthopedics. Produce a transplant in the position of extensor wrists from both sides of the divided muscle of the deep flexor of the fingers. Flexors II, III fingers are connected to the extensor carbide extensions, and IV and V fingers to the elbow extensor of the wrist. To the distal ends of the deep flexor tendons, the proximal ends of the tendon of the superficial flexor of the corresponding fingers are connected with elongation. Symphasic work of flexor flexors of fingers and wrist extensors facilitates rehabilitation and training of patient in work of transposed muscles.

EFFECT: method allows, due to the simultaneous extension of the flexors of the fingers and the transposition of additional motor units to the wrist extensors, to maintain the stabilization of the wrist and the uniformity of the lateral balance of the wrist.

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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 of the wrist and flexors of the wrist. Such a pathology occurs with spastic lesions of the upper limb, ischemic contracture (Volkman), arthrogryposis.

Deformations of a mild degree can be corrected by conservative orthopedics, for example, using splinting, 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 flexors proximal to the beginning of the carpal canal, and the tendons of the deep flexors at the junction of the tendon to the muscle, the distal ends of the tendons of the deep flexors of the three phalangeal fingers are transposed to the proximal ends of the tendons of the surface flexors of the three phalangeal fingers (4).

The problem of isolated flexion contracture in the wrist joint was solved by performing operations, including lengthening or releasing the flexor tendons of the wrist, and creating an anti-traction to the flexors of the wrist by means of tendon-muscle transpositions. The most common technique is that in order to restore the balance of the extensors, the ulnar flexor of the wrist is transplanted into the position of the radial extensor of the hand (Fig. 1). Other donor muscles for transpositions are described: the radial wrist flexor, round pronator (Fig. 2), and brachioradialis muscle (5, 6, 7). The listed muscles are transplanted into the position of both long and short radial extensor of the hand. The calculation of the balance of antagonists on the wrist is very difficult due to the lateral direction of the tendon traction.

In addition, when using multiple tendon-muscle movements, the problem of patient rehabilitation and training to use the displaced muscles always arises.

It is important to note that the above types of surgical interventions solve in isolation the problems of finger flexion contracture and carpal flexion contracture. The solution to the combination of these problems, which is very common in clinical practice, is currently possible due to the simultaneous execution of the above procedures (Epstein-Rozov operation and the transposition of one of the listed muscles into the position of the wrist extensor). We consider such a decision not rational.

The objective of this invention is to develop an effective method for the operative correction of combined flexion contractures of the fingers and hand, in which a significant lengthening of the flexor tendons of the three-phalangeal fingers of the hand is achieved and muscle traction is formed, aimed at extension of the hand 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 flexion contracture of the hand and fingers by implementing the above items:

- significant lengthening of the flexor tendons of the three-phalangeal fingers;

- adjustable strength restoration of the anteroposterior and lateral balance of the wrist;

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

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

- the use as units of donor muscles that are in phase with the recipient muscles.

The result is achieved by performing:

- The intersection of the tendons of the superficial flexors of the three-phalangeal fingers of the hand at the level of the main phalanges, and the tendons of the deep flexors of the three-phalangeal fingers of the hand at the level of the forearm.

- Transpositions of the distal ends of the tendons of the deep flexors of the three-phalangeal fingers with extension to the proximal ends of the tendons of the superficial flexors of the fingers.

- The use of the distal ends of the tendons of the superficial flexors of the fingers for tenodesis of the proximal interphalangeal joints, which prevents the re-extension of these joints.

- Transposition of the proximal ends of the tendons of the deep flexor of the fingers to the rear of the hand and connecting them to the radial and ulnar extensors of the wrist. In this case, it is possible to use, depending on the required extensor force and lateral balance, various combinations of connecting the four abdomen of the donor muscle (deep flexor II-V of the fingers).

The figures depict:

FIG. 1 - transposition of the ulnar flexor of the wrist on a short radial extensor of the wrist:

position 1 - ulnar flexor of the wrist

position 2 - long radial extensor of the wrist

position 3 - short radial extensor of the wrist.

FIG. 2 - Transposition of the circular pronator of the forearm onto the short radial extensor of the wrist:

position 2 - long radial extensor of the wrist

position 3 - short radial extensor of the wrist

position 4 - round pronator

position 5 - brachioradialis muscle.

FIG. 3 - a correction method of combined flexion contracture of the hand and fingers (front view):

position 6 - tendon graft

position 7 - proximal ends of the tendons of the superficial flexor II, III, IV, V fingers

position 8 - legs (distal ends) of the tendons of the superficial flexors II, III, IV, V fingers

position 9 - the proximal part (muscle) of the deep flexor II, III fingers

position 10 - the proximal part (muscle) of the deep flexor of the IV, V fingers

position 11 - the distal ends of the tendons of the deep flexor II, III, IV, V fingers.

FIG. 4 - correction method of combined flexion contracture of the hand and fingers (rear view):

position 2 - long wrist extensor

position 3 - short wrist extensor

position 6 - tendon graft

position 12 - ulnar extensor of the wrist.

FIG. 5 - correction method of combined flexion contracture of the hand and fingers (front view: fingers):

position 8 - legs (distal ends) of the tendons of the superficial flexors II, III, IV, V fingers

position 11 - the distal ends of the tendons of the deep flexor II, III, IV, V fingers

FIG. 6 - the appearance of the arm with combined flexion contracture (clinical example: patient M., 25 years old with left-sided spastic hemiparesis as a result of cerebral palsy).

FIG. 7 - the appearance of the hand on the 14th day after the operation (clinical example: patient M., 25 years old with left-sided spastic hemiparesis as a result of cerebral palsy).

The method is as follows (Fig. 3, 4, 5).

A curved incision along the palmar surface of the forearm provides access to the flexor tendons throughout the area proximal to the carpal ligament, and identifies them. Through accesses along neutral lines on the main phalanges, the legs of the tendons of the superficial flexor II-V fingers are cut off. The remains of the legs of the superficial flexors are fixed to the main phalanx with the formation of tenodesis in the extension position of 180 °, which helps to prevent the extension of the proximal interphalangeal joints. Fixation can be performed using anchors or a transossal suture. Tendons of the superficial flexors are removed to the wound on the forearm and taken to the side. Tendons of the deep flexors are cut off at the beginning of the tendon. If possible, the brush and fingers are brought to a physiological position. If necessary, the flexors of the hand are lengthened (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 a functionally advantageous (neutral) position, the optimal length of the tendons of the finger flexors is selected and their excesses are cut off from the surface flexors. Excess flexors can be used as tendon autografts. The muscle abdomen of the deep flexors is divided between the flexors of the III and IV fingers. Tendon grafts are sutured to them. Skin incisions are made in the projection of the extensor tendons of the wrist (elbow, long radial, short radial), after which they are isolated and mobilized. Of these wounds, channels are subcutaneously bluntly formed along the lateral surfaces of the forearm into the palmar wound towards the ends of the muscles of the deep flexors: from the ulnar side to the flexors of the IV and V fingers, and from the radial side to the flexors of the II and III fingers. Tendon grafts (excess flexor or allografts) are carried out into the canals and fixed to the corresponding tendons of the extensors of the hand with the selection of tone in the physiological position. Then, the distal ends of the tendons of the deep flexors are sutured to the proximal ends of the surface flexors, as during the Epstein-Rozov operation (2, 3). It is possible to perform surgical intervention using tendon allografts for a seam on the extensors, then the calculation of the tone of the finger flexors and excision of their excess is performed after the seam of the extensors of the brush and immediately before the seam of the finger flexors. In cases of combination with other transpositions, for example, on the extensors of the fingers, or lengthening of the flexors of the wrist, the donor muscles are extracted when working with the flexors, and the seam is performed after the seam of the extensors of the brush, but to the seam on the flexors of the fingers.

With excessive traction of the deep flexor, it is possible to connect not all muscle abdomen, but, depending on the balance of the tone, in various combinations. Possible combinations in this case can be from connecting all the abdomen of the donor muscle to one of the recipient tendons, to the described option with a uniformly balanced connection of a pair of muscle abdomen from the ulnar and radial sides. In particular, with severe flexion contracture of the hand and ulnar deviation of the hand, it is possible to connect the tendons from all four abdomen of the deep flexor of the fingers to the long radial extensor of the wrist. When combining flexion contracture of the hand with radiation deviation, it is possible to connect all the abdomen to the elbow extensor of the wrist. If the lateral (ray-elbow) balance of the hand is balanced, the tendons of the deep flexor 2, 3 fingers are connected to the long radial extensor of the wrist, and the tendons of the deep flexor 4, 5 fingers are connected to the elbow extensor of the wrist. Adjustment of the anteroposterior balance is carried out by using a different number of motor units, i.e. it is possible to move and connect not all four muscle abdomen of the deep flexor of the fingers to the recipient tendons, but three, two or one.

Control hemostasis and suture skin wounds. Immobilization is performed with a plaster cast on the forearm-hand-fingers on the back surface. Position: back extension of the hand 120 degrees, flexion in the metacarpophalangeal joints II-V rays of 120 degrees, extension of the interphalangeal joints 180 degrees. In this case, the fingers in the bandage are not fixed. Thus, the possibility of flexion in the metacarpophalangeal joints from 120 degrees to complete bending remains, in interphalangeal joints from 180 degrees to full bending. After 3 weeks, the span can be shortened so that the immobilization of the wrist joint is maintained, the metacarpophalangeal and interphalangeal joints are released. Such a longet lasts for another 3 weeks, in cases of spasticity of the flexors - 5 weeks.

The advantages of this method is that the separation of the donor muscle of the deep flexor and separate connection to the radial (radial) and ulnar extensors of the hand allows you to better adjust the lateral balance of the hand. The presence of 4 separate muscle abdomen in the muscle of the donor allows you to calibrate the strength of the connected motor units.

Muscle biomechanics: the simultaneous tension of the extensors of the wrist and the flexors of the fingers during gripping causes easier retraining of the transposed muscles of a new function.

Clinical example.

Patient M., 25 years old. Diagnosis: cerebral palsy, spastic left-side hemiparesis, combined contracture of the upper limb (Fig. 6). Elimination of contracture was performed using the described technique, in addition it was performed: release of the round pronator, long palmar muscle, transposition of the ulnar flexor of the hand onto the tendons of the common extensor II-V of the fingers, ulnar extensor of the wrist on the long radial extensor of the wrist. A good immediate result was achieved (Fig. 7), the vicious position of the hand was eliminated, and the patient can independently hold the hand in a functional position, it can also bend and unbend fingers in an amplitude sufficient for gripping.

List of references

1. V.V. Umnov et al. Principles of planning surgical treatment of the upper limb in patients with cerebral palsy // Traumatology and Orthopedics of Russia. - 2013 .-- 2 (68). - S. 57-62.

2. MG Carlson Cerebral Palsy: Green's Operative Hand Surgery 5 ^th edition Elsevier, 2005, P 1197-1235.

3. D.G. Finite et al. Orthopedic correction for spastic paralysis of the upper limb. First experience. Conference proceedings: III International Congress "Modern technologies for the diagnosis, treatment and rehabilitation of injuries and diseases of the upper limb", May 16-17, 2013

4. V.V. Umnov, V.A. Novikov, A.V. Zvozil DIAGNOSTICS AND TREATMENT OF SPASTIC HANDS IN CHILDREN WITH CHILDREN'S CEREBRAL PARALYSIS: REVIEW OF LITERATURE PART II. CONSERVATIVE AND SURGICAL TREATMENT OF THE UPPER EXTREMITY // Traumatology and Orthopedics of Russia. - 2011 - 3 (61) S. 137-145.

5. G. Evans Hand And Upper Extremity Reconstruction, Elsevier Limited, 2009, P 193-207.

6. W. Rockwell, C. Stern Tendon Transfers: Plastic Surgery, Indications and Practice 1 ^st Edition, Elsevier Inc, 2009, P 1139-1149.

7. J. Weinzweig Plastic Surgery Secrets Plus, 2nd Edition, 1999 by Mosby, P 825-837.

Claims (4)

1. The method of correction of the combined flexion contracture of the hand and three-phalangeal fingers for spastic paralysis, 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 finger, with an extension, characterized in that the tendons of the superficial flexor of the fingers are cut off at the level of the main phalanges of the fingers, and the tendons of the deep flexor of the fingers - 1 cm proximal to the beginning of the channel the wrists, then transpose the proximal ends of the tendons of the deep flexor of the fingers in the subcutaneous tunnels along the medial and lateral sides of the forearm to the rear and hem them to the extensor tendon or extensor tendons of the wrists with the formation of active traction, extensor wrist, and the distal ends of the tendons of the superficial flexor proximal interphalangeal joints of the II-V fingers. 2. The method according to p. 1, characterized in that with pronounced ulnar deviation of the hand, the muscle abdomen of the deep flexor of the fingers is connected only to the long radial extensor of the wrist. 3. The method according to p. 1, characterized in that during radiation deviation of the hand muscle abdomen of the deep flexor of the fingers are connected only to the long elbow extensor of the wrist. 4. The method according to p. 1, characterized in that when the lateral balance of the hand is balanced, the muscle of the deep flexor to the II, III fingers is connected to the long radial extensor of the wrist, and the belly of the deep flexor to the IV, V fingers is connected to the ulnar extensor of the wrist.

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