RU2741230C1 - Method for formation of distal radioullar joint of forearm - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to traumatology and orthopaedics, and can be used in restoring the ligament apparatus of a radio wall articulation following an injury. Joint is exposed through a longitudinal C-shaped incision along a dorso-elbow surface of a hand and a forearm in a projection of a distal radiolarial articulation with dissection of 5thcanal. Ulcarb is turned into elbow ulnar cavity. Own extensor of 5thfinger on distal level, it is cut off together with parathyon and brought to level of lower one-third of forearm. Radial extensor of wrist is extracted. Canal is drilled in the radial and ulnar bone at the level of the distal radiolar joint. Tendon of the own extensor of 5thfinger is inserted into the formed canal, removed from the radial side and sutured together with a radiomavillar extensor.EFFECT: method provides a good cohesiveness of the distal end, stability and recovery of rotary movements in the distal radiolaric articulation by eliminating dislocation of the ulrobular head, forming radio-ligament ligament with antegrade blood-tight tendon fixed by distal end to blood supply tendon.1 cl, 1 ex, 9 dwg

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used in the restoration of the ligamentous apparatus of the radioulnar articulation after injury.

One of the most difficult problems in wrist surgery is surgical interventions for traumatic ruptures of the distal radioulnar joint. The peculiarity lies in the need to restore the ligamentous apparatus of the articulation and to preserve the function of movement in the radioulnar articulation. There are many known treatments for this category of patients with a ruptured distal radial articulation. So, to prevent recurrence of dislocation of the head of the ulna, it is fixed with a wire to the epiphysis of the radial bone [1]. However, in this case, despite the stability, the mobility of the supination-pronation movements in the joint is lost, which leads to a sharp limitation of the function in the wrist joint.

The closest, in terms of its technical solution, to the claimed method is the "Method for restoring the distal radial articulation of the forearm" [2]. The essence of this method includes access to the joint, channel formation and autotendoplasty. Two longitudinal cuts are made along the radial and ulnar sides of the forearm, at the level of the radioulnar articulation the neck of the ulna is exposed. Through the distal epimetaphysis of the radius, in the frontal plane, two transverse canals are drilled: proximal and distal. The end of the free reinforced autograft is passed through the distal canal from the radial side of the forearm - to the ulnar, and, bypassing the loop around the neck of the ulna, the graft is passed through the proximal canal in the opposite direction. The head of the ulna is fixed in the articular notch of the radial bone, tightening the ends of the graft, tied with a knot, attached to the graft, and the forearm bones are fixed in a neutral position with two needles for 4 weeks. This method is traumatic, the formed ligament does not always hold the head of the ulna stably, the non-blood-supplied autograft is subject to cicatricial degeneration and loss of strength, as a result of which the possibility of palmar-dorsal displacement of the head of the ulna and recurrence of its dislocation is not excluded. With significant physical exertion on the joint, the likelihood of obtaining a pathological fracture of the radial and / or ulnar bone, or rupture of the autograft increases.

The essence of the invention consists in a set of essential features sufficient to achieve the desired technical result, consisting in the elimination of dislocation of the head of the ulna, the formation of a radioulnar ligament with an antegrade blood-supplied tendon, fixed by the distal end to the blood-supplied tendon, which provides good fusion of the distal end, stability and restoration of rotational movements in distal radial junction.

The essence of the method for the formation of the distal radioulnar articulation of the forearm includes access to the joint, the formation of canals and tendoplasty. Access to the joint is carried out through a longitudinal C-shaped incision, 5 cm long, along the dorsal-ulnar surface of the hand and forearm in the projection of the distal radioulnar joint, with the 5th canal dissection, the head of the ulna is set into the ulnar notch of the radial bone. From a separate access, on the rear of the 5th metacarpophalangeal joint, the 5th finger's own extensor is isolated at the distal level, cut off together with the paratenon, and brought to the level of the lower third of the forearm. A longitudinal incision is performed along the radial side of the forearm in the lower third, 2 cm long, and the radial extensor of the wrist is isolated. A canal is drilled in the radius and ulna, at the level of the distal radioulnar articulation, the tendon of the 5th finger's own extensor is passed into the formed canal, it is removed from the radial side, and sutured into a cleft with the radial extensor of the wrist, choosing a moderate tension, which excludes instability of the ulna head. The bones of the forearm are fixed in a neutral position with a wire, the capsule of the distal radioulnar joint is sutured, hemostasis, skin sutures to drainages, an alcohol bandage, plaster cast.

A longitudinal C-shaped incision along the dorsal-ulnar surface of the hand and forearm, in the projection of the distal radioulnar articulation, makes it possible to exclude skin-cicatricial contracture in the postoperative period.

The incision, 5 cm long, provides sufficient space for manipulation in the wound and visualization, and the dissection of the 5th canal allows you to preserve the paratenon, with the vessels passing through it.

Reduction of the head of the ulna into the ulnar notch of the radial bone allows the congruence of the articular surfaces to be restored, which makes it possible to restore the function of the radioulnar joint.

Isolation of the own extensor 5 of the finger at the distal level, cutting it off together with the paratenon, and bringing it to the level of the lower third of the forearm, contributes to the preservation of the antegrade blood supply through the muscle-tendon junction and paratenon, while its length is sufficient for the subsequent stages of the operation. Blood supply to the tendon improves engraftment, reduces the likelihood of cicatricial degeneration, which reduces the risk of rupture. The collection of one's own extensor of the 5th finger does not lead to impaired function of the limb due to the presence of a common extensor of the fingers in each person.

Performing a longitudinal incision, 2 cm long, along the radial side of the forearm in the lower third, and isolating the radial extensor of the wrist, allows visualizing the exit opening of the canal being formed. Isolation of the radial extensor of the wrist is necessary to fix the own extensor of the fifth toe to it, which will ensure the stability of the distal radioulnar articulation.

The formation of a canal in the radius and ulna, at the level of the distal radioulnar junction, allows the formation of a new ligament at the same anatomical place.

Passing the tendon of the own extensor of the 5th finger into the canal formed in the radius and ulna, removing it from the radial side, and suturing into the cleft with the radial extensor of the wrist, provides the function of the lost ligament.

Fixation of the distal end of the tendon, with the selection of its optimal tension, to the radial extensor of the wrist, contributes to the stability of the radial articulation, and better fusion according to the principle “like with like”. Maintaining the blood supply to the receiving bed promotes better tendon fusion.

Fixation with a wire allows you to exclude relapse in the early period, before the tendon fusion.

The restoration of the capsule of the radioulnar joint allows the restoration of the anatomical structures responsible for the functionality and stability of the joint.

The method is explained by the following illustrations, where:

FIG. 1 shows an X-ray CT and 3D image of the anterior dislocation of the head of the ulna, where 1 is the articular surface of the head of the ulna, 2 is the ulnar notch of the radius.

FIG. 2 shows an intraoperative photo of the adjusted dislocation of the ulna head. The ulna is fixed with a wire to the radius, where 1 is the adjusted head of the ulna, 3 is the capsule of the distal radioulnar articulation, 4 is the tendon of the 5th finger's own extensor, moved into the canal together with paratenon, 5 are the extensor tendons of the fingers of the hand;

FIG. 3 shows own extensor 5 of the finger, held in a canal drilled in the radius and ulna at the level of the distal radioulnar articulation, where: 3 - the capsule of the distal radioulnar articulation; 4 - the tendon of the 5th finger's own extensor, moved into the canal together with paratenon; 6 - spoke fixing the radius with the ulna; 5 - extensor tendons of the fingers of the hand; 7 - the area of the sampling of the tendon of the own extensor 5 of the finger in the projection 5 of the metacarpophalangeal joint;

FIG. 4 - suturing the capsule of the joint, where: 1 - adjusted head of the ulna, 3 - capsule of the distal radioulnar articulation, 6 - wire fixing the radius with the ulna;

FIG. 5 - the distal end of the own extensor of the 5th finger is sutured into the radial extensor of the wrist, where: 4 - the tendon of the own extensor of the 5th finger, 8 - the radial extensor of the wrist, 9 - the area of the suture of the tendon of the own extensor of the 5th finger with the radial extensor of the wrist, 6 - the spoke fixing the radial bone with ulna;

FIG. 6 - the result of the operation of patient S. after 2 months;

FIG. 7-a, fig. 7-b, Fig. 7-c shows the functions of the patient S.'s hand 2 months after the operation.

The method is carried out as follows.

After anesthesia and treatment of the skin with an antiseptic, a longitudinal C-shaped incision is made, 5 cm long, along the dorsal-ulnar surface of the hand and forearm in the projection of the distal radioulnar articulation and the head of the ulna, with the 5th canal dissection. The head of the ulna is inserted into the ulnar notch of the radius. From a separate access, on the rear of the 5th metacarpophalangeal joint, the 5th finger's own extensor is isolated at the distal level, cut off together with the paratenon, and brought to the level of the lower third of the forearm. A longitudinal incision, 2 cm long, is performed along the radial side of the forearm in the lower third, and the radial extensor of the wrist is isolated. A canal is drilled in the radius and ulna, at the level of the distal radioulnar articulation. The tendon of the 5th finger's own extensor is passed into the formed canal, removed from the radial side, and sutured into a cleft with the radial extensor of the wrist, selecting a moderate tension, excluding instability of the ulna head. The bones of the forearm are fixed in a neutral position with a wire, the capsule of the distal radioulnar joint is sutured, hemostasis, skin sutures to drainages, an alcohol bandage, plaster cast.

Clinical example.

Patient C, 53 years old. Was admitted to the Department of Traumatology No. 2 GAUZ "RKB MZ RT" 07.10.2019. Diagnosis: closed rupture of the distal radioulnar articulation of the left forearm, with dislocation of the head of the ulna to the palm, 4 weeks ago. Circumstances of the injury: 4 weeks before the visit - fell on her hand near the house. She was treated in a cast for 3 weeks for a bruise. On examination, a dislocation of the head of the ulna was revealed. In the region of the distal radioulnar joint there is dense edema, pain on palpation and movement. Active rotation of the forearm is impossible due to pain. Passives are limited, painful. The gripping function is also impaired due to pain. Finger sensitivity is preserved. No vascular disorders have been identified. To the patient. Performed X-ray computed tomography (RCT) of the lower third of the forearm with the capture of the hand (Fig. 1), standard preoperative examination. No associated diseases were identified. There are no contraindications to surgery.

On October 14, 2019, the operation was performed using the above-described method. Under conduction anesthesia, a longitudinal C-shaped incision was made, 5 cm long, along the dorsal-ulnar surface of the hand and forearm in the projection of the distal radioulnar joint and the head of the ulna, and 5 canals were dissected. A rupture of the dorsum of the capsule of the distal radioulnar joint was revealed. The distal radioulnar junction was opened, the granulation was removed. The head of the ulna was placed into the ulna of the radius (Fig. 2). From a separate access on the back of the 5th metacarpophalangeal joint, the intrinsic extensor 5 of the finger was isolated at the distal level, cut off together with the paratenon (Fig. 3), and brought to the level of the lower third of the forearm. A longitudinal incision was made, 2 cm long, on the radial side of the forearm in the lower third, and the radial extensor of the wrist was isolated. A canal was drilled in the radius and ulna, at the level of the distal radioulnar junction. The tendon of the 5th finger's own extensor was inserted into the formed canal, removed from the radial side, and sutured into a cleft with the radial extensor of the wrist (Fig. 5), choosing a moderate tension, excluding instability of the ulna head. The forearm bones were fixed in a neutral position with a wire. The capsule of the distal radioulnar joint was restored (Fig. 4). Hemostasis, skin sutures before drains, alcohol dressing, gypsum.

Healing by primary intention. The skin sutures were removed after 14 days. The pins were removed 4 weeks after surgery. The patient underwent a single course of physiotherapy.

Control examination 2 months after surgery (Fig. 6). The patient's pain disappeared both at rest and during exertion. The range of motion in the left wrist joint is full. Rotational movements of the left forearm are not limited (Fig. 7-a, Fig. 7-b, Fig. 7-c). There are no symptoms of dislocation of the head of the ulna. The patient is satisfied with the result of the operation.

Thus, the proposed method for the formation of the distal radioulnar articulation of the forearm allows you to set the head of the ulna and restore the functional ligamentous apparatus of the distal radioulnar articulation.

Information sources.

1. Ericka Lawler & Brian D. Adams Reconstruction for DRUJ Instability. HAND (2007) 2: 123-126.

2. RF patent No. 2344776, A61B 17/56, Bul. No. 3, 2009

Claims (1)

A method for the formation of the distal radioulnar articulation of the forearm, including access to the joint, formation of canals and tendoplasty, characterized in that the access to the joint is carried out through a longitudinal C-shaped incision along the dorsal-ulnar surface of the hand and forearm in the projection of the distal radioulnar articulation with a 5-channel incision, length 5 cm, the head of the ulna is set into the ulnar notch of the radius, from a separate access on the back of the 5th metacarpophalangeal joint, the 5th finger's own extensor is isolated at the distal level, cut off together with the tendon sheath and brought to the level of the lower third of the forearm, a longitudinal incision is made along the radial side of the forearm in the lower third, 2 cm long, the radial extensor of the wrist is isolated, a canal is drilled in the radius and ulna at the level of the distal radioulnar articulation, the tendon of the 5th finger's own extensor is inserted into the formed canal, it is removed from the radial side and sutured into a cleft from the radial m with the wrist extensor, selecting a moderate tension that excludes instability of the ulna head, the bones of the forearm are fixed in a neutral position with a wire, the capsule of the distal radioulnar joint is sutured, hemostasis, skin sutures to drainages, an alcohol bandage, plaster cast.

Images