RU2726403C1 - Method for setting of forearm fractures in children - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to traumatology and orthopedics, and can be used for treating diaphyseal forearm fractures in children and adolescents. Method involves fixation of fragments with the help of metal pins. Fracture setting is performed using an external fixation device (EFD) comprising two annular supports. Forearm is placed into a neutral position between pronation and supination. Drill is used to guide the wire in the frontal plane, in the proximal metaphyseal segment of the ulnar bone, and fix it in the base ring EFD. Second pin, also in the frontal plane, is passed through a distal radius section and fixed in the second circular support EFD. Circular supports are connected by threaded rods, through which distraction is carried out by value 1–2 mm higher than displacement value of fragments. Upon completion of reposition, intramedullary two wires are delivered from distal – in proximal forearm bones, external fixation device is dismantled, wires are bent at their entry point. Cast is applied for 4 weeks.EFFECT: method provides reliable and non-damaging skin and soft tissues ensured by low invasiveness.1 cl, 6 dwg, 1 ex

Description

The invention relates to medicine, namely to traumatology and orthopedics, and is intended for the treatment of diaphyseal fractures of the forearm bones in children and adolescents. This type of fracture is characterized by the failure of conservative treatment with the use of closed reduction for oblique and helical fractures, and a high frequency of secondary displacements with successful closed reduction of transverse fractures of the forearm bones. Therefore, in most cases, the predominant method of treating patients with this pathology remains the operative method.

A known method of treating fractures of the forearm bones in children and adolescents using the Ilizarov apparatus, including the imposition of a four-section Ilizarov apparatus [1]. The applied arrangement of the apparatus has good repositional properties, which makes it possible to reposition each forearm bone in isolation, with the possibility of eliminating the rotational displacement of the radius. However, this device also has disadvantages, consisting in the bulkiness of the layout, significant weight and a large number of conductive spokes. The spoke system of reduction, due to the limited "safety corridor" during their implementation, depending on the plane of the fracture and the nature of the displacement of the fragments, is also a disadvantage. Transosseous osteosynthesis during reposition of fragments, performed using pins with stubborn pads, is associated with technical difficulties observed due to various options for displacement of fragments, and a limited "safety corridor" during their implementation, which is associated with the development of iatrogenic neuritis, vascular complications and contractures of adjacent joints.

As a prototype we have chosen "Method of closed reduction of diaphyseal fractures of the radial bone with osteosynthesis with a bundle of strained pins" [2], in which the fixation of fragments is performed using metal pins. After preliminary muscle relaxation, a puncture of the skin along the lateral surface of the radius is performed after 3-4 mm, a trepanation hole with a diameter of 3.0-3.5 mm in the distal metaepiphysis of the radius is 5-7 mm below the styloid process. Through this opening, the first tension-fixing wire with a diameter of 2 mm is inserted into the medullary canal, without bringing it 2-3 mm to the line of the diaphyseal fracture of the radial bone. Using a curved styloid hook inserted through a puncture of the skin at the level of the diaphyseal fracture of the radial bone between the fragments, percutaneous reposition of bone fragments of the diaphyseal fracture of the radial bone is performed. The first stressed wire is passed into the proximal fragment of the radius to a depth of 3-4 diameters of the medullary canal. A curved styloid hook is removed from the space of the radius fracture, the bone fragments are accurately fixed along the line of the diaphyseal fracture, while the rotational and angular displacements of the bone fragments are eliminated. After performing a control X-ray, in the medullary canal of the radial bone, additional strained retaining pins are inserted, parallel to the previously inserted first wire, in the amount of 3-5 pieces, until the medullary canal is completely filled. The ends of the needles are folded and immersed under the skin. The disadvantage of this method is the difficulty in performing the reduction with a curved styloid hook, since it is technically difficult to insert it and get into the intramedullary canal of the proximal fragment. In this case, the skin and soft tissues in the fracture area are additionally injured. Impossibility of reposition during retraction of fragments by muscles.

The essence of the invention is expressed by a set of essential features sufficient to achieve the desired technical result, consisting in providing a simple and reliable reduction, without damaging the integrity of the skin and soft tissues, using an external fixation apparatus, and stable fixation of the diaphyseal fracture of the forearm bones.

The essence of the method for reposition of fractures of the forearm bones in children includes the fixation of fragments with metal pins. The fracture is repositioned using an external fixation apparatus (AVF) containing two annular supports. Set the forearm to a neutral position between pronation and supination. Using a drill, a wire is passed in the frontal plane, in the proximal metaphyseal part of the ulna, and it is fixed in the base ring of the AVF. The second wire, also in the frontal plane, is passed through the distal radius, and fixed in the second annular support of the AVF. The annular supports are connected with threaded rods, along which distraction is performed by an amount 1-2 mm greater than the displacement of the fragments. At the end of the reposition, intramedullary, 2 wires are passed from the distal to the proximal part of the forearm bones, the external fixation device is dismantled, the wires are bent at their entry point. A plaster cast is applied for a period of 4 weeks.

An external fixation device with 2 annular supports allows closed distraction and elimination of the displacement of the forearm bones.

Placing the forearm in a mid-physiological position allows for better reposition.

The use of a drill for holding the spokes is necessary to ensure the installation of the latter in the AVF.

Passing the 1st wire in the proximal metaphyseal part of the ulna, in the frontal plane, with its fixation in the base ring of the AVF, and the second - through the distal part of the radius, also in the frontal plane, with fixation in the second annular support of the AVF ensures elimination of displacement of fragments bones of the forearm.

The connection of the annular supports with threaded rods ensures the assembly of the AVF.

Performing distraction by an amount 1-2 mm greater than the displacement of the fragments creates the possibility of eliminating the displacement of the fragments.

Holding 2 pins at the end of the reduction, intramedullary, from the distal to the proximal forearm bones, provides stable fixation of the forearm bones in the correct position.

Dismantling the external fixation device after reaching the fracture reposition reduces the likelihood of infectious complications and improves the patient's quality of life, since the final fixation of the repaired fragments is carried out using a plaster cast.

Applying a plaster cast for four weeks is enough time for callus to form at the fracture site.

The method is explained by the given X-rays of patient A., 13 years old, where:

In FIG. 1 - pictures of the right forearm in two projections upon admission to the hospital;

In FIG. 2 - the result of the reduction of the forearm bones in the AVF;

In FIG. 3 - intramedullary holding of 2 wires at the end of the reposition, which ensures stable fixation of the forearm bones in the correct position;

In FIG. 4 - a snapshot after dismantling the AVF

In FIG. 5 - view of the forearm for a period of 4 weeks before removing the needles;

In FIG. 6 - the result after removing the needles.

The method is carried out as follows.

After the treatment of the operating field with antiseptic agents, after an unsuccessful attempt at closed reduction, and fixation with the pins of the diaphyseal fracture of the forearm bones, the forearm is set, with the help of an assistant, in the mid-physiological position. Using a drill, the first wire is held in the frontal plane, in the proximal metaphyseal part of the ulna, with its fixation in the base ring. The second wire is passed through the distal radius, also in the frontal plane, with subsequent fixation in the second annular support of the AVF. The ring supports are connected with standard threaded rods. Distraction is performed along the threaded rods connecting both annular supports, by an amount greater than the displacement of fragments by 1-2 mm, at the end of reduction, intramedullary, 2 wires are drawn from the distal to the proximal part of the forearm bones. The external fixation device is dismantled, the needles are bent at their exit point, a plaster cast is applied.

Clinical example

Patient A. was admitted to the Department of Pediatric Traumatology and Orthopedics of GAUZ "RCH MH RT" on May 10, 2019 with a diagnosis of a closed diaphyseal fracture of both bones of the right forearm with displacement. In the admission department, X-rays of the injured forearm were made (Fig. 1), in an emergency, in the operating room, surgical treatment was performed. Under general anesthesia, after treatment of the surgical field with a solution of iodine, alcohol, after an unsuccessful attempt at closed reduction, and fixation, fracture with wires, the forearm was placed, with the help of an assistant, in a mid-physiological position. Using a drill, the first wire was passed in the frontal plane, in the proximal metaphyseal part of the ulna, and fixed in the base ring. The second wire was passed through the distal radius, also in the frontal plane, and fixed in the second annular support of the external fixation apparatus. The ring supports were connected with standard threaded rods. Produced distraction on threaded rods connecting both annular supports by an amount greater than the displacement of fragments by 1-2 mm (Fig. 3). At the end of the reposition, intramedullary, 2 wires were passed from the distal to the proximal part of the forearm bones (Fig. 4). The external fixation device was dismantled. The needles were bent at their exit point, a plaster cast was applied for a period of 4 weeks (Fig. 5). After the surgical treatment, the patient was discharged on the fifth day under the supervision of a traumatologist at the place of residence. After 4 weeks, the pins were removed, after a week the plaster cast was removed (Fig. 6). The patient is referred for rehabilitation treatment.

Sources of information

1. Kudzaev K.U. Treatment of patients with diaphyseal fractures with the Ilizarov method of transosseous osteosynthesis. Abstract dissertation. Cand. honey. sciences. M., 1990, pp. 8-10.

2. RF patent No. 2566917, A61B 17/56, Bul. No. 30, 27.10.2015

Claims (1)

A method of repositioning forearm fractures in children, including fixation of fragments with metal pins, characterized in that the fracture is repositioned using an external fixation apparatus (AVF) containing two annular supports, the forearm is set in a neutral position between pronation and supination using a drill the 1st wire is passed in the proximal metaphyseal part of the ulna, in the frontal plane, it is fixed in the base ring of the AVF, the second wire is passed through the distal part of the radius, also in the frontal plane and fixed in the second annular support of the AVF, the ring supports are connected with threaded rods , by which distraction is performed by an amount, by 1-2 mm greater than the displacement of fragments, at the end of the reposition, intramedullary, 2 pins are drawn from the distal to the proximal part of the forearm bones, the external fixation device is dismantled, the pins are bent at their entrance, a plaster cast is applied for a period of 4 weeks.

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