RU2705234C1 - Method for operative treatment of multi-fragment fractures of surgical neck of humerus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to traumatology and orthopedics, and aims at surgical treatment of multi-fragment fractures of surgical neck of humerus. After access to the proximal shoulder, the subscapular, supraspinatus and infraspinatus muscles are sutured at the sites of their attachment to the tubercles of the humerus. Bone fragments of the proximal fragment are reduced by reducing the threads with which the muscles are implanted. Plate with angular stability is located in the area of a greater tubercle of a humeral bone, placing its front edge backwards from intertubercular transverse of a humeral bone, and its top edge – on 5–8 mm below an apex of a greater tubercle humeral bone. Through the holes in the plate, it is fixed by 4–6 spines to the head of the humerus. Two locking screws are inserted through the proximal portion of the plate into the head of the humerus. Rotational displacement of the head of the humerus relative to the diaphysis is eliminated by rotating the plate around the humerus. 2.5 mm diameter drill is used to form a canal in a distal fragment with gripping two cortical layers directed from the outside to the inside in a frontal plane passing through the longitudinal axis of the humerus. Distal fragment is pulled to the plate with cortical screw 3.5 mm in diameter, which is inserted into the formed canal through the proximal portion of the dynamic opening in the plate; the length of the cortical screw is 6–8 mm greater than the length of the canal. That is followed by distraction of fragments on the plate, wherein the cortical screw is loosened. Anterior-posterior projection eliminates displacement of fragments along the length and fixes the screw in the distal section of the dynamic opening of the plate. Then angular displacement of bone fragments is eliminated, for this purpose the cortical screw is re-loosened. In the lateral projection, the angular displacement is eliminated between the proximal and distal fragments and the screw is repeatedly fixed in the distal section of the dynamic opening of the plate. Then, locking screws are installed in distal and proximal fragments. Cortical screw inserted into the distal fragment through the dynamic hole in the plate is replaced with a screw of a smaller length sufficient for fixing a distal fragment in the distal cortical layer. Reduction pins are removed from the proximal fragment. Threads with which the muscles were previously stitched are interconnected or fixed in the holes of the plate.

EFFECT: method provides simultaneous reduction of traumatism, simplification and improvement of reliability of reposition by using a retainer as a "joystick" when eliminating displacement of fragments.

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Description

The invention relates to medicine, namely to traumatology and orthopedics, and is intended for surgical treatment of fractures of the surgical neck of the humerus.

Bone osteosynthesis for fractures of the surgical neck of the humerus has an important advantage over other osteosynthesis technologies. When performing open access and bone osteosynthesis, in connection with a full review of the surgical field, anatomically correct reduction is achieved, and the risk of injury to nearby neurovascular bundles is reduced. The use of access without muscle dissection significantly improves the quality of life of patients already in the early postoperative period and leads to an improvement in the anatomical and functional results of treatment.

The main problem during osteosynthesis is reposition, which consists in counteracting the muscles of the rotator cuff, which are attached to the large and small tubercles of the humerus. With a fracture of the surgical neck of the humerus, they displace the head of the humerus upward and inward.

The powerful traction of muscles and the short length of the proximal fragment (the head of the humerus) create additional difficulties, both during reposition and when introducing the elements of the fixing structure - plates and screws. All this can lead to an increase in the duration of the operation due to the repeated stages of reposition, an increase in tissue trauma due to repeated attempts to introduce tools and structural elements.

Known methods for surgical treatment of fractures of the surgical neck of the humerus, in which plates are used for osteosynthesis.

The following method is known for the treatment of fractures of the humerus (RU 2523652 C1). First, reposition of the fragments is performed, after which a fixator is applied to the surface of the humeral head and pre-fixed by introducing 2-3 Kirschner spokes, the device is distally fixed to the diaphysis with a 3.5 mm diameter cortical screw.

Also known is a method for bone osteosynthesis of periarticular fractures of the proximal humerus, which we have chosen as a prototype (RU 2238054 C2). After isolation and reposition of fragments of the humerus, the plate is placed on the fragments and, starting from the diaphyseal part, channels are drilled in both corticals and a screw is screwed. The channels in the shoulder head are drilled to the articular surface of the shoulder head, and the screws are screwed into the head in any order.

The disadvantages of the known methods, including the prototype, is the need to perform reposition immediately before installing the fixing devices.

We set the task of reducing the duration and morbidity of the operation of the bone osteosynthesis of a multi-fragmented fracture of the surgical neck of the humerus by simplifying the technique of reposition and retention of fragments, as well as reducing the number of manipulations.

The technical result achieved by the implementation of the invention is to simultaneously reduce the morbidity, simplify and increase the reliability of the reposition by using the latch as a “joystick” while eliminating the displacement of fragments.

Thus, the proposed method ensures that the correct position of the fragments is achieved by fixing the plate to the head of the humerus and using this design as a “joystick”. In this case, the elimination of all types of displacements and temporary fixation of the diaphysis of the humerus is carried out using a cortical screw installed through a dynamic hole in the plate into the initially correctly inserted channel.

Thus, the application of the patented method allows to solve several important problems:

• reduction of morbidity, achievement of anatomically correct reduction, reduction of operation time;

• increase the likelihood of successful reposition 1) by counteracting the muscles of the rotator cuff by increasing the length of the lever by using a fixed plate as a “joystick” and 2) by repositioning the fragments on the plate, sequentially eliminating rotational displacement, length displacement and angular displacement.

The invention consists in the following.

A method for surgical treatment of a three-fragment or four-fragment fractures of a surgical neck of a humerus includes reposition and fixation of fragments using a bone fixer with angular stability. Moreover, after access to the proximal part of the shoulder, the subscapular, supraspinatal and infraspinatus muscles are sutured in the places of their attachment to the tubercles of the humerus. Bone fragments of the proximal fragment are reduced by reducing the threads with which the muscles were stitched.

A plate with angular stability is located in the region of the large tubercle of the humerus, placing its front edge posterior to the intercalcital groove of the humerus, and its upper edge is 5-8 mm below the tip of the large tubercle of the humerus. Through holes in the plate, it is temporarily fixed with 4-6 spokes to the head of the humerus.

Two lockable screws are inserted through the proximal part of the plate into the head of the humerus, and the rotational displacement of the head of the humerus relative to the diaphysis is eliminated by rotation of the plate around the humerus.

Then a drill with a diameter of 2.5 mm form a channel in the distal fragment with the capture of two cortical layers in the direction from the outside inward in the frontal plane passing through the longitudinal axis of the humerus.

The distal fragment is pulled to the plate with a 3.5 mm diameter cortical screw held in the formed channel through the proximal section of the dynamic hole in the plate. The length of the cortical screw is 6-8 mm longer than the length of the canal. After that, fragments are distracted on the plate, while the cortical screw is weakened, the displacement of fragments along the length is eliminated in the anteroposterior projection, and the screw is fixed in the distal section of the plate dynamic hole.

Then, the angular displacement of the bone fragments is eliminated, for which the cortical screw is loosened again, in the lateral projection, the angular displacement between the proximal and distal fragments is eliminated, and the screw is re-fixed in the distal section of the dynamic opening of the plate.

Next, lockable screws are installed in the distal and proximal fragments, the cortical screw installed in the distal fragment is replaced through a dynamic hole in the plate with a screw of a shorter length, sufficient to fix the distal fragment in the distal cortical layer, and the repair needles are removed from the proximal fragment, the threads that were previously stitched muscles, bind to each other or fixed in the holes of the plate.

When the humerus is shortened due to the passage of fragments by 6 mm or less, a channel in the distal fragment can be formed through the proximal part of the dynamic opening of the plate.

When the humerus is shortened due to the penetration of fragments of more than 6 mm, a channel in the distal fragment can be formed outside the plate, having previously shifted it with the fixed proximal fragment to the side after determining the area of insertion of the drill into the distal fragment. After forming the channel, the plate is returned to its original position.

The invention is illustrated by the following figures.

In FIG. 1 illustrates a fracture of the surgical neck of the humerus with angular displacement of fragments and with displacement of fragments along the length and width.

In FIG. 2 illustrates a fracture of the surgical neck of the humerus with angular displacement of fragments, and with displacement of fragments along the length (side view).

In FIG. Figure 3 shows the positioning of a plate with angular stability on a large tubercle of the humerus, posterior to the sulcus of the long tendon of the biceps of the shoulder muscle with its temporary fixation to the head using knitting needles ∅ 1.2 mm.

In FIG. Figure 4 shows the positioning of a plate with angular stability on a large tubercle of the humerus, posterior to the sulcus of the long tendon of the biceps of the shoulder muscle and parallel to the axis of the proximal fragment, with its temporary fixation to the head using knitting needles ∅ 1.2 mm (side view).

In FIG. Figure 5 shows two screws installed through the most proximal lockable holes in the plate.

In FIG. Figure 6 shows two screws installed through the most proximal lockable holes in the plate (side view).

In FIG. 7 shows the formation of the channel with a drill ∅ 2.5 mm in the distal fragment of the humerus through a dynamic hole in the plate.

In FIG. Figure 8 shows the formation of a channel in the distal fragment of the humerus through a dynamic hole in the plate (side view).

In FIG. Figure 9 shows the formation of the channel in the distal fragment of the humerus with a displaced plate (side view).

In FIG. 10 - through a dynamic hole in the plate, a cortical screw через 3.5 mm (side view) is installed in the formed channel.

In FIG. 11 - the distal fragment is attracted to the plate using a cortical screw.

In FIG. 12 - reflects the position of the screw in the dynamic hole after eliminating the offset along the length.

In FIG. 13 - the position of the screw in the dynamic hole is reflected after eliminating the displacement along the length, the angular displacement of the fragments and their displacement along the width (side view) are preserved.

In FIG. 14 - angular displacement and offset in width are eliminated, the direction of the plate is parallel to the axis of the distal fragment (side view).

In FIG. Figure 15 shows the final fixation of the distal fragment by two lockable screws (side view).

In FIG. 16 shows the replacement of the cortical screw with a screw with a shorter length sufficient to be fixed to the distal cortical layer.

In FIG. 17 shows the final stage of the operation: lockable screws are installed in the head of the humerus through the proximal part of the plate, temporary spokes are removed.

The following positions are indicated in the figures: 1 - head of the humerus, 2 - small tubercle of the humerus, 3 - large tubercle of the humerus, 4 - plate with angular stability, 5 - fixing knitting needles, 6 - lockable screws in the head of the humerus, 7 - channel in the distal fragment of the humerus ∅ 2.5 mm, 8 - cortical screw, 9 - lockable screws in the diaphysis of the humerus.

The method is as follows.

In a patient with a fracture of the surgical neck of the humerus, shown schematically in FIG. 1, FIG. 2, where the head, small and large tubercles of the humerus (positions 1, 2, 3, respectively) are indicated, deltoid-pectoral access to the proximal shoulder is made. A skin incision 10-12 cm long begins from the coracoid process of the scapula and is extended to the upper third of the shoulder, dissected subcutaneous fat and muscles are dilated to expose the fracture site.

At 3-4 fragmentary fractures, the subscapular, supraspinatus and infraspinatus muscles are sutured at the sites of their attachment to the tubercles of the humerus. Achieve information of bone fragments of the proximal fragment of the humerus to each other by reducing the threads that pierced the muscles.

Position the plate (4) with angular stability in the region of the large tubercle of the humerus. In this case, the front edge of the plate is placed posterior to the inter-tubercle groove of the humerus, and its upper edge is 5-8 mm below the tip of the large tubercle of the humerus (Fig. 3, Fig. 4). The direction of the plate should be parallel to the longitudinal axis of the proximal fragment. Through holes in the plate, it is temporarily fixed with 4-6 spokes (5) to the head of the humerus. Perform EOP control of the position of the plate in the anteroposterior and axial projections.

Through the proximal part of the plate, 2 lockable screws (6) are inserted into the head of the humerus. A plate fixed to the head of the humerus with two screws and knitting needles represents a robust structure that can be manipulated by repositioning the head of the humerus (Fig. 5, Fig. 6).

Performing the reposition stages according to the proposed method requires the installation of a cortical screw in the distal fragment through a dynamic hole in the plate. To hold this screw in the distal fragment, it is necessary to first properly lay the channel. To mark the point for the beginning of the formation of the channel, a short-term reposition of the fracture is performed, manually manipulating the fragments.

Eliminate the rotational displacement of the shoulder head relative to the diaphysis. This stage of reposition is performed by rotating the plate around the humerus, using the distal part of the plate as a manipulator (“joystick”), achieving its location on the lateral surface of the distal fragment of the humerus. An external epicondyle of the shoulder, which is located on the lateral side of the lower third of the humerus, is used as a guideline to determine the required degree of rotation.

The image intensifier tube is monitored for the position of the plate in the front-rear and axial projections.

Then, with a drill with a diameter of 2.5 mm, a channel (7) is formed in the distal fragment of the humerus through its entire thickness (with the capture of two cortical layers) from the outside inward in the direction transverse to the longitudinal axis of the humerus, so that it passes through the maximum diameter the cross section of the humerus, dividing the aforementioned cross section of the humerus into the anterior and posterior halves (Fig. 7). Channel (7) is located in the frontal plane passing through the longitudinal axis of the humerus.

The channel (7) can be formed through the top of the dynamic hole in the plate, provided that the bone is shortened due to the passage of fragments to 6 mm (6 mm or less) (Fig. 8).

When shortening the bone due to the penetration of fragments of more than 6 mm, the formation of the channel is performed outside the plate, moving it with a fixed proximal fragment of the fracture to the side after determining the area of introduction of the drill into the distal fragment (Fig. 9). After drilling the channel, the plate is returned to its original position.

The distance (B) from the upper edge of the distal fragment to the channel (7) (or the channel formation level (7)) can be calculated by the formula B = A + 3 (in mm), where A is the distance from the lower edge of the proximal fragment to the upper ( proximal) edges of the dynamic plate opening.

The distal fragment is attracted to the plate with a 3.5 mm diameter cortical screw (8), drawn into the formed channel through the proximal section of the dynamic hole in the plate. The length of the screw (8) should be 6-8 mm longer than the size obtained by measuring the length of the channel, which will temporarily weaken the fixation of the plate to the distal fragment, but maintain the fixation of the screw to both cortical layers of the distal fragment. This will simplify the attraction of the fragment to the plate and will allow to fully fix the screw in the cortical layers (Fig. 10, Fig. 11).

The image intensifier tube is monitored for the position of the plate in the anteroposterior and axial projections. The result of this stage should be almost complete elimination of the displacement of fragments across the width in the axial plane and fixation of rotation.

The next step on the plate is the distraction of fragments. For this, the cortical screw (8) is loosened, under the control of the image intensifier tube in the anteroposterior projection, the displacement along the length is eliminated and the screw is re-fixed in the dynamic hole more distally (Fig. 12, Fig. 13).

The last stage of reposition is the elimination of angular displacement. For this, the cortical screw is loosened, under the control of the image intensifier in the lateral projection, the angular displacement between the proximal and distal fragments is eliminated and the screw is re-fixed in the dynamic hole at the same level (in the distal section of the dynamic hole of the plate). At the end of this stage, the plate should be located along the axis of the distal fragment (Fig. 14).

The image intensifier tube is monitored for the position of the plate in the anteroposterior and axial projections.

Next, the locking screws (9) are installed in the diaphysis of the humerus (Fig. 15). The cortical screw (8) is replaced with a screw of a shorter length, sufficient for fixation in the distal cortical layer of the distal fragment (Fig. 16).

Lockable screws ∅ 3.5 mm (6) are installed in the proximal fragment in accordance with the number of holes (Fig. 17).

The rehearsing needles (5) are removed from the proximal fragment. The threads with which the muscles of the rotator cuff of the shoulder are stitched are connected to each other or fixed in the holes of the plate.

The surgical wound is sutured in layers.

Thus, a plate fixed to the head of the humerus with two screws and knitting needles represents a robust structure that can be manipulated when repositioning fragments. All stages of distal fragment reposition are performed on a plate using a cortical screw. A channel for the cortical screw is formed in the distal fragment of the humerus through its entire thickness (with the capture of two cortical layers) from outside to inside in the direction transverse to the longitudinal axis of the humerus, so that it passes through the maximum cross-sectional diameter of the humerus, separating the above the cross section of the humerus to the anterior and posterior halves. Rotational displacement is eliminated by installing the screw strictly in the frontal plane of the humerus. The offset along the length is eliminated by moving the screw in the dynamic hole. The shift in width in the frontal plane is eliminated due to the attraction of the distal fragment to the plate with a cortical screw. The last step is the elimination of angular deformation and the final fixation of the plate.

Clinical example 1.

Patient K., 53 years old. Household injury - fell at home on the area of the right shoulder. Delivered by an ambulance to the hospital with a diagnosis of Closed three-fragment fracture of the surgical neck of the right humerus with displacement of fragments. On the 2nd day the patient underwent surgery: open reposition of fragments and bone osteosynthesis according to the proposed method. In this case, a plate with angular stability was located 5 mm below the tip of the large tubercle of the humerus, 4 spokes were used for temporary fixation, and the length of the cortical screw was 6 mm longer than the length of the channel formed in the distal fragment passing through two cortical layers.

All radiographs of the shoulder joint were performed in two projections. On control radiographs after 6 weeks from the moment of surgery, consolidation of a fracture of the right humerus was achieved. On examination, after 18 weeks from the moment of the operation, the function of the right shoulder joint was restored, the range of movements was complete, and there was no pain syndrome.

Clinical example 2.

Patient B., 61 years old. Household injury - fell on the street on the left shoulder area. She independently came to the City Clinical Hospital No. 1. A four-fragment fracture of the surgical neck of the left humerus with displacement of fragments was revealed. On the 9th day, the patient underwent surgery: an open reposition of fragments and bone osteosynthesis according to the proposed method. At the same time, a plate with angular stability was located 8 mm below the tip of the large tubercle of the humerus, 6 spokes were used for temporary fixation, and the length of the cortical screw was 8 mm longer than the length of the channel formed in the distal fragment passing through two cortical layers.

All radiographs of the shoulder joint were performed in two projections. On control radiographs after 6 weeks from the moment of surgery, consolidation of a fracture of the right humerus was achieved. On examination, after 18 weeks from the moment of the operation, the function of the right shoulder joint was restored, the range of movements was complete, and there was no pain syndrome.

Thus, the advantage of the proposed method for the reposition of fragments in fractures of the surgical neck of the humerus is the reduction in the duration of the operation, the reduction of tissue trauma, due to the reposition of the fracture on the plate. In this case, the elimination of all types of displacements and temporary fixation of the diaphysis of the humerus is carried out using a cortical screw installed through a dynamic hole in the plate into the initially correctly inserted channel. The proposed technique of surgery avoids prolonged traction of the limb in order to counter the strength of the muscles of the shoulder girdle.

Claims (3)

1. A method for the surgical treatment of three-fragment or four-fragment fractures of the surgical neck of the humerus, including reposition and fixation of fragments using a osseous fixator with angular stability, characterized in that after access to the proximal part of the shoulder, the subscapular, supraspinatal and infraspinatus muscles are sutured at the points of attachment to the tubercles the humerus, reduce bone fragments of the proximal fragment by converting the filaments with which the muscles were stitched; they have a plate with angular stability in the region of the large tubercle of the humerus, placing its front edge posterior to the intermuscular groove of the humerus, and its upper edge is 5-8 mm below the tip of the large tubercle of the humerus; through the holes in the plate, it is temporarily fixed with 4-6 knitting needles to the head of the humerus; through the proximal part of the plate, two lockable screws are inserted into the head of the humerus, the rotational displacement of the head of the humerus relative to the diaphysis is eliminated by rotating the plate around the humerus; then a drill with a diameter of 2.5 mm form a channel in the distal fragment with the capture of two cortical layers in the direction from the outside inward in the frontal plane passing through the longitudinal axis of the humerus; attracting the distal fragment to the plate with a 3.5 mm diameter cortical screw drawn into the formed channel through the proximal section of the dynamic hole in the plate, while the length of the cortical screw is 6-8 mm longer than the channel length; whereupon the fragments are distracted on the plate, while the cortical screw is weakened, the displacement of the fragments along the length is eliminated in the anteroposterior projection, and the screw is fixed in the distal section of the plate dynamic hole; then eliminate the angular displacement of bone fragments, for which the cortical screw is again loosened, in the lateral projection eliminate the angular displacement between the proximal and distal fragments and re-fix the screw in the distal section of the dynamic opening of the plate; then the lockable screws are inserted into the distal and proximal fragments, the cortical screw installed in the distal fragment through the dynamic hole in the plate is replaced with a screw of a shorter length sufficient to fix it in the distal cortical layer of the distal fragment, the repair needles are removed from the proximal fragment, the threads that previously muscles were stitched, connected to each other or fixed in the holes of the plate. 2. The method according to p. 1, characterized in that when shortening the humerus due to the entry of fragments by 6 mm or less, the channel in the distal fragment is formed through the proximal part of the dynamic hole of the plate. 3. The method according to p. 1, characterized in that when shortening the humerus due to the entry of fragments of more than 6 mm, the channel in the distal fragment is formed outside the plate, after having shifted it with the fixed proximal fragment to the side after determining the area of introduction of the drill into the distal fragment, and after the formation of the channel, the plate is returned to its original position.

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