RU2700257C1 - Thorax carcass recovery device - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery and traumatology and orthopedics. Device for restoring the carcass of the thorax is represented by an external fixation apparatus (EFA), Kirschner wires, ulcer wire and parts of the Ilizarov apparatus. Device consists of two parts. First part comprises an EFA, namely an EFA outer frame mounted above the thorax with a floatation "rib panel" by means of Schanz rods mounted on both clavicles and iliac bone on the side of the injury. Second portion comprises 4 Kirschner wires with diameter of 1.5 mm implanted in the patient's chest tissue over the region of the floatation "rib panel", a horizontal segment of the first Kirschner wire having a ring-shaped end is implanted above the external surface of the ribs of the thorax, next two wires are successively inserted under periphery of horizontal section of previous pin, and the last pin, except for insertion under the peripheral part of the horizontal segment of the previous pin, is inserted above the horizontal segment of the first pin, thus providing mutual coupling of the pins in the tissues above the floatation "rib panel". Cutaneous passages implanted in the tissue of the spokes are interconnected by an ulcer wire. Ring-shaped end of the first pin is fixed in moderate tension to the outer frame of EFA over the final fracture of the ribs by means of the parts of the set of Ilizarov apparatus.

EFFECT: invention provides higher clinical effectiveness in the patients with a thoracic injury and multiple fractures of the ribs.

1 cl, 10 dwg

Description

The invention relates to medicine, namely to medical devices used in surgery and traumatology and orthopedics.

In case of multiple fractures of the ribs along two or more lines, a “rib valve” or a floating “rib panel” with a violation of the skeleton of the chest and the inability to create negative pressure in it due to the paradoxical movements of the chest wall. In this case, the "rib valve" falls on the inspiration and expands on the exhale. Such gross disturbances in the biomechanics of breathing for several hours can cause a critical gas exchange disorder, pleuro-pulmonary shock, cardiopulmonary syndrome and adult respiratory distress syndrome (RDSV), which result in terminal pulmonary edema and death.

Analogs

To prevent these complications, various methods and devices are used to fix the "rib panel", which can be divided into three groups. The first group includes fixation of the "rib valve" with knitting needles or tools wound behind the back surface of the ribs (Fig. 1, a, b, c). Using these devices, the "rib panel" is pulled, which ensures the possibility of creating negative pressure in the chest. However, a significant drawback of analogues is the risk of iatrogenic penetrating wound of the chest, damage to the intercostal vessels and nerves with significant bleeding and painful intercostal neuralgia. The second group (Fig. 2, a, b, c) includes methods for osteosynthesis of ribs with needles. For this group, along with the disadvantages inherent in the first group, it is unlikely that the spokes will be accurately closed at the specified points and directions for drilling the ribs (all the more so, longitudinally or at an acute angle when the spoke slides off the rounded surface of the narrow rib). The same group (and with the same drawbacks) includes the method of traction over the sternum (Fig. 3, a, b), proposed by E.G. Gryaznukhin (1994).

Criticism of analogues

Therefore, the disadvantages of analogues are the following:

- the risk of iatrogenic damage to the intercostal vessels and nerves with significant bleeding and painful intercostal neuralgia;

- high risk of iatrogenic penetrating wound of the chest;

- the improbability of the closed execution of the exact conduct of the knitting needles at given points and directions of drilling ribs, especially longitudinally or at an acute angle, when the spoke slides off the rounded surface of a narrow rib.

Prototype

As a prototype device, we selected a device from a safer third group (Fig. 4, a, b), described in the National Guide to Traumatology (2008) and presented in figure 4, b. An advantage of the prototype is the possibility of the least traumatic closed achievement of the immobilization of the rib panel.

Prototype criticism

However, the prototype device has significant disadvantages:

- too high a load per unit area of the skin in places of fixation of the device to the surface of the chest in combination with a low effect of this fixation - due to the elasticity of the skin;

- due to too high a load per unit area of the skin in the places of fixation of the device during respiratory movements of the chest, the development of internal pressure sores and teething occur;

- the need for a variety of such seams - to achieve the effect of immobilization of the costal panel and reduce the load on the skin under each of the seams;

- the accumulation of wound discharge under the perforated plate of the device, which can cause maceration, pressure sores and the risk of inflammation of the soft tissues of the chest;

- restriction of access to the chest and visual control of its skin;

- the need to search for parts for the manufacture of the device, usually not included in the arsenal of treatment tools for surgical and trauma departments.

The purpose of the invention is to increase the efficiency of treatment of patients with multiple fractures of the ribs along two or more lines, accompanied by flotation of the "rib panel".

SUMMARY OF THE INVENTION

The goal is realized by the use of a device for restoring the skeleton of the chest, represented by an external fixation apparatus (AVF), Kirchner knitting needles, cerclage wire and Ilizarov apparatus kit parts, characterized in that it consists of two parts, the first of which includes the AVF, namely the external frame AVF (pos. 1), mounted above the rib cage with a floating “rib panel” using Schantz rods (pos. 2), mounted on both collarbone and ilium on the injured side, and the second part including t 4 Kirschner curved spokes (Fig. 6, b) 1.5 mm diameter, implanted into the tissue of the chest of the patient over the area of a floating "rib panels." The Kirchner needle (pos. 3) has a horizontal segment (pos. 4) and vertical (pos. 5), and the first spoke (Fig. 6, a) has a ring-shaped end (pos. 6). In this case, the length of the vertical segment of the knitting needle (item 5) is 5-10 cm (so that it can stand 4-7 cm above the skin during implantation in the chest), and the length of the horizontal segment (item 4) is dictated by the area of the floating “rib panel” and usually varies from 9 to 15 cm. For an even distribution of the load on the horizontal segments of the knitting needles, and also so that their ends do not protrude from under the skin, it is advisable that the curvature of the horizontal part of the knitting needles (item 4) corresponds to the curvature of the ribcage above the implantation site of the fragments knitting needles Apply the spokes of the device to restore the skeleton of the chest as follows (Fig. 6, b). Before injecting a knitting needle (pos. 3), a rubber stopper from a penicillin bottle is placed on it. The first Kirschner needle (pos. 3), having a ring-shaped end (pos. 6), is implanted in the tissue above the outer surface of the ribs of the chest; the next two knitting needles (pos. 3) are sequentially inserted under the peripheral part of the horizontal segment (pos. 4) of the previous knitting needle, and the last knitting needle, besides introducing under the peripheral part of the horizontal stretch of the previous knitting needle, is inserted with its tip over the horizontal segment of the first knitting needle, which ensures mutual coupling knitting needles in the tissues above the floating "rib panel" (Fig. 6, b). The cutaneous segments (pos. 5) of the spokes implanted in the tissue (pos. 3) are connected to each other (Fig. 7) by a cerclage wire (pos. 7), and the annular end (pos. 6) of the first spoke (pos. 3) using parts Ilizarov’s apparatus, namely a threaded rod (pos. 8), an arm (pos. 9), nuts (pos. 10), bolts (pos. 11), a 33-mm plate (pos. 12) and a 60-mm plate (pos. . 13), fix in moderate tension to the frame of the AVF (pos. 1) over a graduated fracture of the ribs. In this case, the tension for mutually interconnected spokes (pos. 3) is carried out by manual traction for the threaded rod (pos. 8) in the range of 1.5-2 kg, after which the nuts relaxed on it (pos. 10) counter-tighten, thereby securing the achieved position a threaded rod (key 8) on the bracket (key 9). This traction over the floating "rib panel" at the same minute eliminates gross disorders of the biomechanics of respiration and ensures the creation of negative pressure in it.

Device application example

As an example of the use of this device, the following observation. Patient R., 76 years old, was admitted to the RTC on 06/08/18 after a catastrophe with a diagnosis of Combined trauma. A severe brain contusion. Closed chest injury. Multiple fractures of II-X ribs of the right half of the chest along two or more lines with the displacement and flotation of the "rib panel". Rupture of the right lung. Right-sided hemo-pneumothorax. Closed abdominal injury. Closed comminuted fracture of the middle third of the right femur with displacement of fragments. Multiple abrasions. Traumatic shock of the III degree.

Against the background of intensive infusion-transfusion therapy, an operation was performed: Thulococentesis according to Bulau on the right. Laparocentesis with abdominal drainage. Osteosynthesis of the right femur with rod-shaped AVF. Due to the presence of multiple fractures of the ribs along two or more lines (Fig. 8) and flotation of the “rib panel” with the growing phenomena of life-threatening acute respiratory failure, the relief of which is a priority measure of the highest urgency, indications were given for emergency use of the frame restoration device chest

On 06/06/18 g, the first stage of the operation was applied by AFF to the right half of the chest above the floating “rib panel” using Shants rods mounted on both clavicles and the right ilium (Fig. 9). The second stage of the operation used 4 Kirschner spokes, 1.5 mm in diameter, which were implanted in the chest tissue above the area of the floating “rib panel”. Before injecting the spokes, rubber plugs were planted on them. The first spoke, having a ring-shaped end, was implanted in the tissue above the outer surface of the ribs. The next spoke is inserted under the peripheral part of the horizontal segment of the first spoke, perpendicular to it. Then, the third knitting needle is drawn under the peripheral part of the horizontal segment of the previous knitting needle, and the last knitting needle, besides introducing the third knitting needle under the peripheral part of the horizontal knitting needle, is inserted with its tip over the horizontal segment of the first knitting needle. This ensured the mutual coupling of the spokes in the tissues above the floating “rib panel”. The cutaneous segments of the knitting needles implanted in the tissue were connected by a cerclage wire, and the annular end of the first knitting needle, using parts of the Ilizarov apparatus, was fixed in moderate tension to the AVF frame over the terminal fracture of the ribs (Fig. 10). In this case, the tension for mutually linked knitting needles was carried out manually within 1.5 kg, which immediately eliminated gross disorders of the biomechanics of respiration and ensured the creation of negative pressure in the chest. The lung straightened, and breathing was heard in all fields. The result of restoring the skeleton of the chest is regarded by us as good.

Signs of the invention, distinctive from the prototype:

- the use of standard Kirschner and AVF spokes;

- Conducting Shantz rods through both clavicles and the ilium of the side of the terminal fracture of the ribs;

- the shape of the Kirschner spokes used, having a horizontal and vertical length, and the first spoke has a ring-shaped end. In this case, the length of the vertical segment of the knitting needle is 5-10 cm (so that it can stand 4-7 cm above the skin during implantation in the chest), and the length of the horizontal segment is dictated by the area of the floating “rib panel” and usually varies from 9 to 15 cm. For uniform load distribution on the horizontal segments of the spoke fragments, their curvature corresponds to the curvature of the chest above the implantation site of the spoke fragments;

- a certain procedure for holding Kirschner knitting needles for their mutual linking in the tissues of the chest, namely: the first Kirchner knitting needle having a ring-shaped end is implanted in the tissue above the outer surface of the rib cage; the next two knitting needles are sequentially inserted under the peripheral part of the horizontal segment of the previous knitting needle, and the last knitting needle, besides introducing the horizontal segment of the previous knitting needle under the peripheral part of the knitting needle, is inserted with its tip over the horizontal segment of the first knitting needle;

- the cutaneous segments of the spokes implanted in the tissue are connected with each other with a cerclage wire, and the annular end of the first spoke with the help of the Ilizarov apparatus parts is fixed in tension within 1.5-2 kg to the AVF frame;

- the use of parts of the Ilizarov apparatus, namely, a threaded rod, bracket, nuts, bolts, a 33 mm plate and a 60 mm plate, which are fixed in moderate tension of the spokes to the AVF frame over the terminal fracture of the ribs. In this case, the tension for mutually interconnected spokes is carried out by a manual traction for the threaded rod in the range of 1.5-2 kg, which is fixed to the bracket by counter-tightening the nuts.

The technical result (advantages over the prototype) of the device for restoring the carcass of the chest with multiple fracture of the ribs:

- restoration of the chest frame and ventilation function of the lungs with the elimination of paradoxical breathing;

- fixation of the device from the knitting needles to the chest by an external fixation device using three Shantz rods inserted into the clavicles and the ilium makes the device more compact and eliminates the need to use the Balkan frame and rollers for traction;

- the rational arrangement of the fragments of the spokes ensures their mutual coupling in the soft tissues;

- fixing the cutaneous segments of the spokes to each other with a cerclage wire enhances their mutual coupling in soft tissues above the floating “rib panel”;

- mutual coupling of the spokes makes them more stable and eliminates their deformation and migration even with a diameter of spokes of 1.5 mm, which leads to their minimally invasiveness and prevention of the risk of inflammation of the tissues of the chest;

- uniform distribution of the load per unit area of the fragments of the spokes implanted in the tissue and a sufficient contact area with the soft tissues of the chest, which prevents the development of internal pressure sores and teething;

- the ability to vary the size and shape of the device depending on the nature of the fracture, the size and shape of the rib panel;

- the ability to adjust the level and direction of traction of Kirchner spokes interconnected, depending on the location of the fracture of the ribs, which is ensured by the location of the rod apparatus of external fixation and parts of the set of Ilizarov apparatus on the external support of the AVF;

- the ability to adjust the thrust of mutually interconnected spokes with a manual thrust within 1.5-2 kg for a threaded rod, which is fixed to the bracket by counter-tightening the nuts;

- simplicity, cost-effectiveness and the absence of the need to search for parts for manufacture, since the Kirchner knitting needles, the core AVF and the Ilizarov apparatus kit are included in the arsenal of therapeutic agents used in traumatology and orthopedics.

Thus, this device can significantly improve the results of treatment, and often save the lives of patients with multiple fractures of the ribs, and can be recommended for implementation in wide clinical practice of surgical and trauma departments of medical institutions of various levels.

Information taken into account:

1) Ostroverkhoe G.E., Bomash Yu.M., Lubotsky D.N. Operative surgery and topographic anatomy. - M: Medical Information Agency LLC, 2005. - 736 p., S. 436-461;

2) Traumatology and Orthopedics: A Guide for Physicians / Ed. N.V. Kornilova: in 4 volumes. - St. Petersburg: Hippocrates, 2006.- T. 4: Injuries and diseases of the pelvis, chest, spine, head / Ed. N.V. Kornilova and E.G. Gryaznukhina. - St. Petersburg: Hippocrates, 2006 .-- 624 p. - S. 104-131.

3) Traumatology: national leadership / ed. G.P. Kotelnikova, S.P. Mironova. - M.: GEOTAR-Media, 2008 .-- 808 p. - (Series "National Guides"), S. 315-319 - prototype device.

Claims (1)

A device for restoring the skeleton of the chest, represented by an external fixation apparatus (AVF), Kirchner knitting needles, cerclage wire and parts of the Ilizarov apparatus set, characterized in that it consists of two parts, the first of which includes the AFF, namely the external frame of the AFF mounted above chest with a floating “rib panel” using Schantz rods mounted on both collarbone and ilium on the lesion side, and the second part includes 4 curved Kirschner spokes with a diameter of 1.5 mm, implanted data in the patient’s chest tissue over the area of the floating “rib panel”, a horizontal segment of the first Kirschner needle having a ring-shaped end is implanted over the outer surface of the rib cage, the next two needles are sequentially inserted under the peripheral part of the horizontal segment of the previous needle, and the last needle, except introducing under the peripheral part of the horizontal segment of the previous knitting needle, is introduced over the horizontal segment of the first knitting needle, thereby providing mutual coupling of the knitting needles in the tissues over the floating cabbage "rib panel"; the cutaneous segments of the knitting needles implanted in the tissue are connected with a cerclage wire, and the annular end of the first knitting needle is fixed in moderate tension to the external frame of the AFF over the terminal fracture of the ribs using the parts of the Ilizarov apparatus.

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