RU2762103C1 - Method for preventing the cicatrical adhesion of the radial nerve after osteosynthesis of fractures of the humerus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to traumatology, orthopedics and neurosurgery, and can be used to prevent the formation of the cicatrical adhesion process of the radial nerve after osteosynthesis of shoulder fractures. After osteosynthesis of the diaphyseal fracture of the shoulder, a substitute for the dura mater is placed between the isolated radial nerve and the bone fragments of the humerus, which is cut along the length of the isolated radial nerve and applied with a smooth side to the nerve, before this the flap is moistened with sterile saline solution. The flap is fixed with atraumatic sutures to soft tissues.

EFFECT: method prevents fusion of the radial nerve and the soft tissues surrounding the bone and reduces the risk of complications due to the formation of a layer of collagen tissue between the radial nerve and the humerus.

1 cl, 4 dwg, 3 ex

Description

The invention relates to medicine, namely to traumatology, orthopedics and neurosurgery, is intended for the prevention of the formation of cicatricial adhesions of the radial nerve after osteosynthesis of shoulder fractures with plates of various modifications.

After osteosynthesis and in the process of regeneration and fusion of bone fragments, as a result of the release of the radial nerve, a cicatricial adhesion process is formed, which causes difficulties in removing the metal structure after consolidation of the fracture and can lead to post-traumatic neuropathy of the radial nerve.

A known method for the prevention of cicatricial compression of the nerve, traumatic peripheral paralysis and paresis, including the intraoperative introduction of an experimental animal of sterile hydrogel polymer of sodium salt of carboxymethylcellulose in the amount of two milliliters in the area of traumatic nerve injury in such a way as to create a "barrier" between the nerve and injured tissues [RF Patent No. 2379040, 20.01.2010]. The disadvantages of the method are: experimental use, in a patient, the introduction of the gel can cause an allergic reaction due to the individual characteristics of the organism, in addition, the introduction of the gel into the nerve contributes to the hydraulic injury of the damaged nerve.

The closest analogue of the invention is a method of preventing the development of cicatricial adhesions in the epidural space after removal of a herniated disc at the lumbar level, characterized by the fact that the yellow ligament is partially removed in the medial part between the arcuate space above the dural sac while maintaining the integrity of the yellow ligament and the periosteum in lateral sections above the spine. In this case, a fragment of epidural fat is used as a fragment of adipose tissue, its displacement is carried out in the caudal and cranial directions, while maintaining the vessels with feeding legs. After removing the herniated intervertebral disc, the epidural space around the root and dural sac is filled with an anti-adhesion gel in a volume of 2-3 ml. Then a fragment of epidural fatty tissue is straightened and the defect of the yellow ligament is filled, as well as the dorsal surface of the root and dural sac. Then a second layer of anti-adhesion gel is applied to the epidural fragment of adipose tissue over the defect of the yellow ligament in a volume of 1-2 ml, limiting the muscle tissue [RF Patent No. 2709248 of 12/17/2019]. The disadvantages of the prototype are: a high risk of formation of a cicatricial adhesive process and the likelihood of migration of adhesive gel with active drainage of the wound, there is also a risk of displacement of the ligamentum flap, which can lead to compression of the nerve.

The objective of the invention is to prevent the formation of cicatricial adhesions of the radial nerve in the osteosynthesis of the humerus.

The technical result when using the invention is an increase in the therapeutic effect due to the formation of a layer of collagen tissue between the radial nerve and the humerus, which prevents dense fusion of the radial nerve and the soft tissues surrounding the bone, reducing the risk of complications.

The essence of the invention is illustrated by the following figures: FIG. 1 shows a skin section, where: 1 - the fracture line of the humerus, 2 - the humerus; in fig. 2 - mobilization and isolation of the radial nerve, where: 3 - mobilized radial nerve on the holder; in fig. 3 - extraosseous osteosynthesis with a plate, where: 4 - extraosseous plate; in fig. 4 - placing the dura substitute, where: 5 - dura substitute.

The proposed method for the prevention of the formation of cicatricial adhesions of the radial nerve after osteosynthesis of the humerus is as follows. A skin incision is performed using an anteroposterior or posterior approach (Fig. 1). It is impossible to operate in the middle or lower third of the shoulder without isolating the radial nerve and not seeing it, because it may be traumatized. Before the main stage of the operation, a search and visualization of the radial nerve in the wound is performed, the radial nerve is carefully isolated together with the accompanying vessels. With the help of a dissector, rubber bands-holders are carried out, which help to follow the nerve, and during the operation they hold the nerve in the desired position (Fig. 2). Through the interval between the outer head of the triceps brachii muscle and the outer edge of the biceps brachii muscle, they exit onto the humerus. Fragments are exposed sparingly subperiosteally. Bone fragments are repositioned, stabilized and osteosynthesis with a plate, which provides stable functional osteosynthesis (Fig. 3). For osteosynthesis of diaphyseal fractures of the shoulder, wide straight plates and narrow straight plates are most often used. Plates with 7-8-9 holes are required for reliable fixation of the diaphyseal fracture of the shoulder. At the end of the operation, before closing the wound, to prevent cicatricial adhesions around the isolated radial nerve and to avoid additional nerve injury, a dura mater substitute such as Lyoplant®, Neuro-Patch®, Duraform and others. Cut out the flap of the dura mater of the required shape, along the length of the isolated radial nerve and apply the smooth side to the nerve, before that the flap is moistened with sterile saline (Fig. 4). An atraumatic, tension-free suture is used to fix the flap to prevent tearing of the dura substitute. After that, layer-by-layer sutures are applied to the wound, rubber drainage and an aseptic dressing. During the regeneration process, the laid dura mater substitute prevents the formation of cicatricial adhesions around the exposed radial nerve and bone tissue with a plate.

The implementation of the invention is illustrated by the following examples.

Clinical example 1.

Patient B., 27 years old, was taken by ambulance to the GBUZ RB GKB No. 21 in Ufa after falling on the street with complaints of pain, deformity, crepitus of fragments in the middle third of the left shoulder. An examination was carried out, examination by a duty traumatologist, radiography was performed in frontal and lateral projections. The X-ray shows a transverse fracture of the left humerus with displacement of fragments. After clinical analysis and appropriate preparation, the patient underwent surgery: bone osteosynthesis with an 8-hole plate with angular stability. An antero-external approach was made, a layer-by-layer incision, the radial nerve was highlighted, which was retracted to the side for better visualization of the fracture site. There is a transverse fracture of the left humerus with displacement and interposition of fragments by soft tissues. The fragments were freshened, matched and fixed with an angularly stable 8-hole bone plate. The plate was fixed with 4 cortical and 4 angularly stable screws. Functionally stable osteosynthesis was performed. A Lyoplant® dura substitute flap was excised along the length of the exposed radial nerve, moistened with sterile saline and placed smooth side to the nerve. The flap is fixed with sutures to the soft tissues. The control was carried out on an electronic-optical converter (EOC). On control, reduction was achieved, osteosynthesis was stable. After that, layer-by-layer sutures were applied to the wound, rubber drainage, and aseptic dressing. After wound healing, 10 days later, she was discharged for outpatient follow-up treatment at the clinic to a traumatologist. She applied again after 1 year for the removal of metal structures. On the roentgenogram after 1 year: a consolidated fracture with the presence of metal structures. The function of the left upper limb is in full. Surgical treatment was performed in a planned manner: removal of the metal structure under conduction anesthesia. The operation revealed that there is no cicatricial adhesive process around the radial nerve. The radial nerve was easily exposed during the mobilization of the radial nerve. The plate was removed and a dura substitute was placed between the radial nerve and the humerus again. Layered sutures on the wound, aseptic dressing. The wound healed by primary intention and the patient was discharged with recovery. No complications were observed. A good functional result and complete social and medical rehabilitation were obtained.

Clinical example 2.

Patient P., 56 years old, was taken by ambulance to the GBUZ RB GKB No. 21 in Ufa after an accident, was hit by a car while crossing the street. An examination was carried out, examination by a duty traumatologist, radiography was performed in frontal and lateral projections. The radiograph shows a comminuted fracture of the right humerus in the middle third with displacement of fragments. After clinical analysis and appropriate preparation, the patient underwent surgery: bone osteosynthesis with a plate with angular stability for 10 holes. An antero-external approach was made, a layered incision, the radial nerve was highlighted, which was retracted to the side for better visualization of the fracture site. There is a comminuted fracture of the right humerus with displacement and interposition of fragments by soft tissues. The fragments were freshened, matched and fixed with an angularly stable 10-hole bone plate. The plate was fixed with 4 cortical and 5 angularly stable screws. Functionally stable osteosynthesis was performed. The Neuro-Patch® dura substitute flap was excised along the length of the exposed radial nerve, moistened with sterile saline, and placed smoothly against the nerve. The flap is fixed with sutures to the soft tissues. The control on the image intensifier was carried out. On control, reduction was achieved, osteosynthesis was stable. After that, layer-by-layer sutures were applied to the wound, rubber drainage, and aseptic dressing. After the wound healed, 10 days later, he was discharged for outpatient follow-up treatment at the clinic to a traumatologist. He applied again after 1.5 years for the removal of metal structures. On the roentgenogram after 1.5 years: a consolidated fracture of the right one with the presence of metal structures. The function of the right upper limb is in full. Surgical treatment was performed in a planned manner: removal of the metal structure under conduction anesthesia. The operation revealed that there is no cicatricial adhesive process around the radial nerve. The radial nerve was easily exposed during the mobilization of the radial nerve. The plate was removed and a dura substitute was placed between the radial nerve and the humerus again. Layered sutures on the wound, aseptic dressing. The wound healed by primary intention and the patient was discharged with recovery, no complications were observed. A good functional result and complete social and medical rehabilitation were obtained.

Clinical example 3.

Patient B., 36 years old, was taken by ambulance to GBUZ RB GKB No. 21 in Ufa after falling from a height of 2 meters. An industrial injury fell from a ladder. Complaints of pain, deformity, crepitus of fragments in the middle third of the left shoulder, inability to lift the left hand, numbness of the left hand. An examination was carried out, an examination by a duty traumatologist, a neurosurgeon, radiography was performed in frontal and lateral projections. The radiograph shows a comminuted fracture of the left humerus with displacement of fragments in the middle third. A clinical diagnosis was made: a closed comminuted fracture of the left humerus with displacement of fragments in the middle third, complicated by posttraumatic neuropathy of the radial nerve. After clinical analysis and appropriate preparation, the patient underwent surgery: bone osteosynthesis with a plate with angular stability for 10 holes. An antero-external approach was made, a layer-by-layer incision, there is a transverse fracture of the left humerus with displacement and interposition of fragments by soft tissues and the radial nerve. The radial nerve is highlighted, which is retracted to the side for better visualization of the fracture site. The fragments were freshened, matched and fixed with a plate with angular stability for 10 holes. The plate was fixed with 4 cortical and 5 angularly stable screws. The control on the image intensifier was carried out. On control, reduction was achieved, osteosynthesis was stable. The Duraform dura substitute flap was excised along the length of the exposed radial nerve, moistened with sterile saline solution, and applied with the smooth side to the nerve. The flap is fixed with sutures to the soft tissues. Layer-by-layer sutures were applied to the wound, rubber drainage, aseptic dressing. After wound healing, 10 days later, she was discharged for outpatient follow-up care at the clinic to a traumatologist and neurologist. On the roentgenogram after 1 year: a consolidated fracture with the presence of metal structures. The function of the left upper limb was in full, signs of neuropathy of the radial nerve were arrested. There are no neurological symptoms. A good functional result and complete social and medical rehabilitation were obtained.

Thus, the placement of the dura mater substitute between the isolated radial nerve and bone fragments of the humerus prevents the formation of scars and adhesions during the regeneration of soft tissues and consolidation of the fracture of the humerus. A layer of collagen tissue formed between the radial nerve and the humerus prevents dense fusion of the radial nerve and the soft tissues surrounding the bone, reduces the likelihood of complications, and promotes the most rapid restoration of the motor function of the limb.

Claims (1)

A method of preventing the formation of cicatricial adhesions of the radial nerve after osteosynthesis of fractures of the humerus, including the creation of a barrier between the nerve and bone tissues, characterized in that between the isolated radial nerve and bone fragments of the humerus, a collagen-based dura mater substitute is placed, cut along the length of the isolated radial nerve and moistened with saline, smooth side to the nerve and fix it with atraumatic suture material without tension.

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