RU2686001C1 - Method of surgical correction of hand deformity in paralysis of vermiform and interosseous muscles - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to orthopaedics, neurosurgery, reconstructive surgery, and can be used for correction of paresis and paralysis of upper extremity with involvement of vermicular and interosseous muscles. Tenodesis of the flexor tendons is carried out to the main phalanges of II-V fingers. On each of said fingers, tenodesis is performed in a position of flexion of a finger in a proximal interphalangeal joint to angle of 170° by performing a transosseal suture, fixing both legs of the surface flexor to the main phalanx of the finger without cutting off the attachment point of said tendon to its middle phalanx.

EFFECT: method provides improved functional capabilities of hand, prevention of overextension in proximal interphalangeal joints and reduced time of hand immobilization due to partial redirection of thrust of superficial fingers to proximal phalanges of II-V fingers.

1 cl, 6 dwg, 1 ex

Description

The invention relates to medicine, namely to orthopedics, neurosurgery, reconstructive surgery, and can be used in correcting the effects of paresis and paralysis of the upper limb with damage to the worm-like and interosseous muscles of the hand.

These conditions are formed in the lesions of the nervous system at various levels. In the absence of the function of short muscles, a specific deformity of the hand occurs, which is expressed not only in a change in appearance, which is associated with muscle atrophy, but also a violation of the biomechanics of the hand, since the aforementioned muscle group has an organizing function. The interosseous and worm-like muscles stabilize the metacarpophalangeal joints (PPS) and take part in the flexion of the fingers, and in the extension of the fingers. Isolated loss of function of these muscles occurs, for example, with lesions of the ulnar nerve (or its motor branch). In this case, a deformity is formed, which is expressed in the absence of active extension of the interphalangeal joints of the fourth, fifth fingers (sometimes second, third, fourth, fifth fingers), and when trying to unbend these fingers, the metacarpophalangeal joints are over-extended. In addition, when the fingers are bent, there is a weakening of the cylindrical gripper, and in severe cases the lack of full gripping due to the impossibility of completely bringing the tips of the three phalangeal fingers to the palm.

In cases of more extensive lesions, such as damage to several nerves, brachial plexus, spinal cord (at a level above Th1), all short muscles of the hand may suffer, while, even with successful recovery of nerves, the deformity persists due to irreversible muscle atrophy. Therefore, the complex of surgical rehabilitation, as a rule, includes procedures aimed at compensating the deficiency of the function of short muscles [1]. For injuries to the ulnar nerve, interventions are described to stabilize the metacarpophalangeal joints of II-V fingers. This allows you to restore the active extension of the fingers. For example, stabilization of the PFC can be achieved by performing a shortening capsuleraffia proposed by E. Zancolli. [2], in which the palmar portion of the capsule of the metacarpophalangeal joints is shortened and fixed.

Static procedures are also described, consisting in the formation of tenodesis limiting the re-extension of the metacarpophalangeal joints using various grafts and methods of their fixation [3, 4, 5].

Surgical procedures seem to be biomechanically justified, in which the lack of function of short muscles is compensated by connecting to their tendons or to the main phalanges of other motor units.

For example, as a stage of surgical rehabilitation for tetraplegia, the so-called. “Hand resuscitation” often perform the procedure “Lasso Zankolli” (“Zancolli lasso”) [6], in which the legs of the surface flexor are cut off from the attachment to the middle phalanx and are carried out over the annular ligament A2 in the proximal direction and hemmed onto themselves with the formation of a loop around the palmar portion of the bone-fibrous channel of flexor tendons at the level of the main phalanx (Fig. 1). Thus, the place of application of the force of the surface flexor from the middle phalanx to the main one changes. The tendon controls the main phalanx through the ligamentous apparatus - the fibrous channel of the tendon. The disadvantage of this method is that it is possible to stretch the ligament, because of which the degree of correction is reduced.

Possible fixation of the legs of the superficial flexor or tendon graft to the side bundles of the extensor apparatus (Fig. 2), as in the operation proposed by House [4]. This allows you to further enhance the extension of the interphalangeal joints. A more reliable fixation of the legs of the surface flexor directly to the main phalanx [7] (Fig. 3). Achieving a stronger fixation of the legs, without a loss of degree of correction, is possible in two ways:

- the legs of the surface flexor after clipping are carried out in a pre-drilled channel in the phalanx, and then sewed;

- after clipping, the legs of the surface flexor can be circled around the phalanx under the extension apparatus and also sewn together.

The disadvantages of these methods include: the need for long-term immobilization for reliable adhesion of the tendons, as well as the probability of formation of hyperextension in the proximal interphalangeal joints during normal or increased work of the extensors (for example, with spasticity).

The technical result of the invention consists in improving the functionality of the hand by compensating for the deficiency of the function of the worm-like and interosseous muscles, preventing over-bending in the proximal interphalangeal joints and minimizing the immobilization time.

The result of the invention is achieved by partially redirecting the surface flexor of the fingers of the hand through the tenodes of the surface flexor to the proximal phalanxes of the II-V fingers, and tenodesis on each specified finger is produced in the position of flexion of the finger in the proximal interphalangeal joint to an angle of 170 ° by performing transosal suture fixing both legs of the tendon of the superficial flexor to the main phalanx of the finger without cutting off the point of attachment of the specified tendon to its middle halyard ange

The figures depict:

FIG. 1 - Method "Lasso Zankolli" (connection of the legs of the surface flexor to the annular ligament);

FIG. 2 - House method (connecting the graft to the lateral bundles of the extensor apparatus of the finger;

FIG. 3 - Burkhalter method (connection of the tendon graft to the main phalanx using a transosseal suture);

4 is a diagram. The method of surgical correction of the deformity of the hand with paralysis of the worm-like and interosseous muscles;

FIG. 5 - Clinical example. Patient K., effects of spinal cord injury. Before surgery: the absence of a gripper when attempting to flex and a tendency to hyperextension of the metacarpophalangeal joints during extension;

FIG. 6 - Clinical example. Patient K. After surgery: the possibility of a cylindrical gripper is restored. The method is as follows:

Access to the main phalanx and the osteo-fibrous canal of flexor tendons in the neutral lateral line of the three phalangeal finger on its non-working surface (on the II, III fingers - on the elbow side, on the IV, V fingers - on the radial side). The bone fibrous channel is opened and flexor tendons are removed from the bone with a hook. A channel is drilled at the level of the middle third of the main phalanx in the frontal plane with a Kirschner spoke (D 1.2 mm). The needle is brought to the skin opposite the entry point and a 2-3 mm puncture of the skin is performed at the exit point of the skin (mini-access). A thread with a needle is passed through the formed channel and led out through the completed mini-access. Put notches on the periosteum along the entire palmar surface of the main phalanx to stimulate the adhesion of the tendon. Then apply to the places of the incisions of the tendon of the surface of the flexor. The proximal interphalangeal joint is placed in the flexion position to an angle of 170 degrees and the needle is held with the thread in the opposite direction: from the mini-access to the main wound, stitching the flexor tendon under visual control. At the same time, in the contact zone of the surface and deep flexor of the finger, the thread must be completely covered with the tendon of the surface flexor, so that there is no contact of the thread with the tendon of the deep flexor. Tighten the loop and tie a knot. Check to preserve the mobility of the tendon of the deep flexor of the finger. Sew up the skin. Similarly, repeat the procedure on the remaining three-phalanx fingers (Fig. 4).

The proposed method allows to reduce the risk of failure of re-fixation of the legs of the surface flexor of the fingers, because the tendon of the surface flexor is not cut off from the site of attachment, which allows not to immobilize and give early functional load, and subsequently a greater physical load, which, in turn, makes it possible to rehabilitate the brush earlier and more fully. This is especially important when complex, multi-component correction is performed.

The procedure is simple to perform and takes significantly less operating time compared to peers, and also does not require the use of special materials and tools.

Clinical example

Patient K, 31 years old, suffered a spinal injury: a fracture of the cervical vertebra C5 with damage to the spinal cord and the formation of tetraparesis. At the level of the hands and forearms, the shoulder-beam muscles and the short radial extensors of the wrist are preserved. The remaining muscles underwent atrophy. The extensor fingers are spastic (Fig. 5).

The first step is performed tenodesy by the described method. The remaining stages of the restoration of the gripper by carrying out flexor tenodesis at the level of the forearm are performed as standard.

A satisfactory cylindrical gripper of the hand is achieved, allowing the patient to independently take objects with his hand and release them. The patient began to use the limb when eating and hygienic procedures (Fig. 6).

References

1. Zancolli E. Structural and dynamic bases of hand surgery. 2nd ed. Philadelphia: JB Lippincott, 1979, 375p.

2. Zancolli E.A. Claw hand caused by paralysis of the intrinsic muscles. A simple surgical procedure for its correction. J Bone Joint Surg. 1957; 39a: 1076-1080.

3. Rodomanova LA, Davydov Yu.V., Kaptulina G.V. patent RU 2288662 of December 10, 2006.

4. House J.H., Shannon, MA Restoration of the body and the patient pinned in tetraplegia. J Hand Surg Am. 1985; 10 (1): 22e29.

5. Jones N.F .: Tendon transfers in the upper extremity / Plastic Surgery by P.C. Neligan ,, Saunders, 2012, - P: 735-776.e3.

6. Zancolli E. Correccion de la '' garra '' digital por paralysis intrinseca. La operacion del 'lazo'. Acta Ortop Latinoam. 1974; 1: 65-71.

7. Burkhalter W.E. Restoration of power grip in ulnar nerve paralysis. Orthop Clin North Am 1974 Apr; 5 (2): 289-303.

Claims (1)

Method for surgical correction of hand deformity with paralysis of worm-like and interosseous muscles, including tenodesis of superficial flexor tendons to the main phalanges of II-V fingers, characterized in that on each of said fingers, tenodesis is produced in the position of flexion of the finger in the proximal interphalangeal joint up to an angle of 170 ° by performing a transosseal suture that fixes both legs of the tendon of the superficial flexor to the main phalanx of the finger without cutting off the point of attachment of the specified tendon to its middle fa lange.

Images