RU2733685C1 - Method of accessing proximal interphalangeal joint of fingers in intra-articular injuries and lesions - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to traumatology and orthopedics, and can be used for access to a proximal interphalangeal joint (PIPJ) of fingers in intraarticular injuries and injuries. Method involves access to the palmar surface of the main and middle phalanges, separation of the neurovascular bundle and its shift aside, dissection of the ligament. Perform U-shaped access. Collateral ligament is dissected lengthwise to the periosteum, preserving tendon sheaths. Periosteum is separated with the retractor together with the tendon sheath of the flexor, the flexor retainers, palmar plate, additional collateral ligaments and a joint capsule; the separated tendon-periosteal-volar complex is moved aside to the side opposite to the incision, exposing the PIPJ. Hyperextension is performed in PIPJ - shot-gunning and the main stage of the operation is performed. Said complex is laid back and sutured. Fibers of the longitudinally dissected collateral ligament are sutured with the absorbable suture, the wound and the donor region are closed.

EFFECT: method provides reducing the length of treatment and enabling full visualization of the articular surface and enables to avoid tendon contractures by selecting the required graft and maintaining tendon sheaths.

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Description

The invention relates to medicine, specifically to hand surgery, and is used for intra-articular injuries and lesions of the proximal interphalangeal joints.

The urgency of the problem of intra-articular fractures is undoubted, since with this injury, complete destruction of the joint often occurs, leading to a persistent loss of function of the finger. According to statistics from the US Department of Emergency Medicine, 1130 upper limb injuries occur per 100 thousand of the population [1].

According to statistics, fractures of the tubular bones of the hand account for 3% of all injuries, 34% of fractures of the skeletal bones and 50% -65% of fractures of the bones of the hand; consolidation disorders occur in 11-31% of the total number of patients with these injuries [2].

The known method of access to the proximal interphalangeal joint (PMPS) V-shaped Brunner incision along the palmar surface, with dissection of the tendon sheath, palmar plate and joint capsule, followed by hyperextension and dislocation of the joint ("shot-gunning") [3]. On the palmar surface of the main and middle phalanges, a V-shaped incision is made, with the apex above the PMPS. The neurovascular bundle is isolated and pushed aside. The tendon sheath is opened. The flexor tendons are shifted to the side, then the palmar plate and the joint capsule are opened, the lateral collateral ligaments are transversely dissected and the joint is dislocated. The disadvantages of the operation include significant damage to the tendon sheath in the critical (second) zone, joint stabilizers, in the form of a palmar plate, and collateral ligaments, leading to finger contracture.

The closest way is the V-shaped approach along the palmar surface, with the isolation of the tendon-periosteal-volar complex [4]. On the palmar surface of the main and middle phalanges, a V-shaped incision is made, with the apex above the PMPS. The neurovascular bundle is isolated and pushed aside. Additional collateral ligaments are dissected, freeing them from the palmar plate. The periosteum is separated from the bones of the middle and main phalanges by unpacking, thereby preserving the lateral collateral ligaments on one side, and on the other - the periosteal-tendon-ligamentous complex with the palmar plate. However, this technique does not allow performing hyperextension in the PMFJ - shot-gunning - it restricts the collateral ligament, and thus fully visualizes the articular surface of the base of the middle phalanx, which is especially difficult in chronic injuries, since lateral ligaments are retracted.

The essence of the invention is expressed by a set of essential features sufficient to achieve the desired technical result, and consists in the possibility of full visualization of the articular surface, the convenience of selecting the necessary graft, and the preservation of tendon sheaths avoids tendon contractures and shortens the treatment time.

The essence of the method of access to the proximal interphalangeal joint of the fingers in case of intra-articular injuries and lesions includes access along the palmar surface of the main and middle phalanges, isolation of the neurovascular bundle, its shift, and dissection of the ligament. The access can be U-shaped, the collateral ligament is dissected along to the periosteum, preserving the tendon sheaths. The periosteum is separated with a raspor together with the flexor tendon sheath, flexor retainers, the palmar plate, additional collateral ligaments, and the joint capsule. The isolated tendon-periosteal volar complex is moved away from the incision side, exposing the PMPS, hyperextension is performed in the PMPS - shot-gunning, and the main stage of the operation is performed. The mentioned complex is placed in place and sutured along the edges, the fibers of the longitudinally dissected collateral ligament are sutured with an absorbable suture, the wound and donor area are sutured.

The use of a U-shaped incision improves visualization of the PMFS. Longitudinal dissection of the collateral ligament, with the separation of the periosteum, allows you to preserve the connections of the tendon sheath of the flexors, flexor retainers, palmar plate, and additional collateral ligaments and the joint capsule;

The execution of hyperextension in PMFS - shot-gunning improves the visualization of the joint.

Putting the tendon-periosteal-volar complex in place allows you to preserve the stabilizing apparatus of the PMPS, the motor apparatus of the flexors of the finger.

Suturing of collateral ligaments ensures the preservation of their stabilizing function.

The accompanying illustrations illustrate a given clinical example, where:

in FIG. 1 - shows the scheme of access to the proximal interphalangeal joint, where 1 - skin incision, 2 - projection of the neurovascular bundle, 3 - the level of separation of the tendon-periosteal-volar complex;

in FIG. 2 - RCT of patient V.'s hand upon admission to treatment;

in FIG. 3, FIG. 4, FIG. 5, Fig. 6 - mitraoperative photos of the stages of the operation of a clinical example;

in FIG. 3 - U-shaped access to the PMFS;

in FIG. 4 - isolation of the tendon-periosteal-volar complex;

in FIG. 5 - hyperextension of PMPS with visualization of the affected area of the bone;

in FIG. 6 - autologous plastic with screw fixation;

in FIG. 7 - X-ray of patient V.'s hand after surgery,

in FIG. 8, Fig. 9 - the functional result of patient B. 3 months after the operation.

The method is carried out in the following way.

A U-shaped incision is made along the palmar surface of the main and middle phalanges. Allocate and raise the fatty skin flap to the opposite side, isolate the neurovascular bundle and shift it. The collateral ligament is visualized. It is dissected lengthwise to the periosteum, while maintaining the tendon sheaths. The periosteum is separated by unpacking together with the tendon sheath of the flexors, flexor retainers, the palmar plate, and additional collateral ligaments and the joint capsule. The isolated tendon-periosteal-volar complex is moved in the direction opposite to the incision, exposing the PMPS. Hyperextension is performed in PMFS - shot-gunning. In this case, the entire articular surface of the main and middle phalanges is visualized. The main stage of the operation is performed. The mentioned complex is laid in place, and hemmed along the edges. The fibers of the longitudinally dissected collateral ligament are sutured with an absorbable suture. The wound is sutured, the donor area.

Clinical example

Patient V., 42 years old, was admitted for treatment to the Republican Scientific and Practical Trauma Center of GAUZ "RKB MH RT" on July 13, 2019, 1 month after the injury, with a diagnosis of "Old fracture dislocation of the middle phalanx of 4 fingers of the right hand." The injury was received in everyday life, while playing volleyball. Was not treated. In connection with the persistence of pain and limitation of movements, he turned to the emergency room, from where he was sent to the Republican Scientific and Practical Center for Trauma of the RCH. Under conduction anesthesia, after preliminary exsanguination of the limb, patient V. underwent an operation: "Open reduction of dislocation, autologous plasty with a fragment of the hook-shaped bone". The access was made according to the method developed by us. A U-shaped incision was made along the palmar surface of the main and middle phalanges of 4 fingers. Allocated, and raised, the skin and fat flap to the opposite side. The neurovascular bundle was isolated and removed. The collateral ligament was visualized, dissected lengthwise to the periosteum, while preserving the tendon sheaths. The periosteum was removed by unpacking together with the flexor tendon sheath, flexor retainers, palmar plate, and additional collateral ligaments and the joint capsule. The isolated tendon-periosteal-volar complex was moved to the opposite side from the incision, exposing the PMPS. Hyperextension was performed in PMFS - shot-gunning. The entire articular surface of the main and middle phalanges of the finger was visualized. The destroyed portions of the base of the middle phalanx were removed. After marking, autologous plasty was performed with a fragment of a hook-shaped bone, osteosynthesis with screws. We put the mentioned complex in place, under or along the edges. Fibers of a longitudinally dissected collateral ligament in or with absorbable suture, in or in a wound. The wounds healed by primary intention, without complications. The patient is satisfied with the achieved result.

Sources of information

1. Hand (N.Y). 2012 Mar; 7 (1): 18-22 Daan Ootes.

2. Clinical practice guidelines Hand and wrist fractures Year of approval (frequency of revision): 2017 (revision every 3 years). ID: KP414. URL. Professional associations. All-Russian public organization. Association of Orthopedic Traumatologists of Russia (ATOP).

3. Williams RM, Kiefhaber TR, Sommerkamp TG, Stern PJ. Treatment of unstable dorsal proximal interphalangeal fracture / dislocations using a hemi-hamate autograft. J Hand Surg Am. 2003, 28: 856-65.

(

Department of Trauma & Orthopaedics, Percviall Pott Rotation, Royal London Hospital, London, UK), Shirley Stougie

(

Department of Plastic Surgery, Erasmus MC, Rotterdam, The Netherlands), Jan H. Coert

(

Department of Plastic Surgery, Erasmus MC, Rotterdam, The Netherlands).4. Hemi-Hamate Autograft Arthroplasty for the Proximal Interphalangeal Joint Revisited: A New Surgical Approach Patrick KY Goon * (* Department of Hand Surgery, Lister Hospital, Stevenage), Kalpesh R. Vaghelaf

(

Department of Trauma & Orthopedics, Percviall Pott Rotation, Royal London Hospital, London, UK), Shirley Stougie

(

Department of Plastic Surgery, Erasmus MC, Rotterdam, The Netherlands), Jan H. Coert

(

Department of Plastic Surgery, Erasmus MC, Rotterdam, The Netherlands).

Claims (1)

A method of access to the proximal interphalangeal joint (PMFJ) of the fingers in case of intra-articular injuries and lesions, including access along the palmar surface of the main and middle phalanges, isolation of the neurovascular bundle and shifting it to the side, dissection of the ligament, characterized in that the U-shaped access is performed, the collateral ligament is dissected lengthwise to the periosteum, preserving the tendon sheaths, the raspator separates the periosteum together with the tendon sheath of the flexors, flexor retainers, the palmar plate, additional collateral ligaments and the capsule of the joint, the separated tendon-periosteal-side of the volar complex is pushed back from this PMFS, hyperextension is performed in PMFS - shot-gunning and the main stage of the operation is performed, the said complex is placed in place and sutured along the edges, the fibers of the longitudinally dissected collateral ligament are sutured with an absorbable thread, the wound and donor area are sutured.

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