RU2766769C1 - Method of treating chronic monteggia dislocation fracture - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to traumatology and orthopaedics, and can be used in treating old montage fracture dislocation. Pin is inserted intramedularly into the ulnar bone. X-ray image is used to determine the actual shortening of the ulnar bone in relation to the radial bone, and the apex of the deformation formed by fused fragments of the ulna. Percutaneous osteoperforation is performed on an apex of an angular deformation of an ulnar bone, and its subsequent closed osteoclasia. Two-section external fixation device is mounted and a primary distraction is performed. After 5-6 days, distraction and formation of bone regenerate of ulnar bone are started by moving nuts along threaded bars connecting annular supports of the apparatus. Curved distraction regenerate is formed by moving the nut on a remote standard bracket fixing the pin with a thrust platform on the distraction rod with a slot installed on the distal annular support of the external fixation device. At the same time, distraction is performed with nuts along the threaded rods of the external fixation device. Radial head dislocation is corrected by moving a pin with a thrust platform fixed in a distraction rod with a slot installed on a bracket of a proximal annular support. After X-ray control, the apparatus is stabilized for 6 weeks. Intramedullary pin is removed in 2–3 weeks after bone remodelling of regenerate.

EFFECT: method enables reducing the number of injuries of the intervention, improving the anatomical and functional outcomes of the treatment while reducing the length of treatment due to the combination of techniques of the claimed invention.

1 cl, 6 dwg, 1 ex

Description

The invention relates to medicine, namely to orthopedics, and can be used in the treatment of chronic fracture-dislocation of Montage.

Chronic fracture-dislocation of Monteggia is characterized by a fracture of the upper third of the ulna with angular displacement of the fragments, dislocation of the head of the radius, rupture of the annular ligament, and a significant period of more than 2 weeks from the moment of injury. Fragments of the ulna are fused, as a rule, at an angle, the apex of which is directed to the radial side. At the same time, due to the angle of deformation, there is a shortening of the ulna relative to the radius, a decrease in the interosseous gap, a weakening of the tension of the interosseous membrane, due to which even an openly set head of the radius is not held in the joint. With a significant period from the moment of injury, the growth of the radius, devoid of emphasis in the humeroradial joint, becomes excessively intense, as a result of which the length of the radius becomes longer than the length of the radius on a healthy limb. These features of Montage's fracture-dislocation in children determine a significant number of unsatisfactory outcomes of surgery and the ineffectiveness of conservative methods of its treatment.

A known method for the treatment of chronic isolated dislocation of the head of the radius in children [RF patent No. 2033761, A61V 17/56, BI No. 12, 1995], including arthrotomy of the humeroradial joint with excision of scars, and open reduction of the head of the radius. The radial head is held by restoring the interosseous space by osteotomy of the ulna, applying a two-section Ilizarov distraction apparatus, placing fragments of the ulna with the formation of a regenerate with an angle open to the radial side, and turning the head of the radius until the interosseous membrane is tensioned. The method is traumatic, since an open reduction of the head of the radius is performed, which, in turn, is fraught with frequent arthrogenic complications. The used two-section layout of the Ilizarov apparatus, with deliberately long, uncontrollable, levers for controlling the bone fragments of the ulna, does not allow tensioning the interosseous membrane. To turn the fragments on the spokes, their significant intersection is necessary when installed on supports, which is impossible in these areas of the forearm due to anatomical features - the risk of damage to significant neurovascular formations.

The closest, in terms of its technical solution, is a method for the treatment of chronic fracture-dislocation of Montage [RF patent No. 2363409 A61V 17/56, BI No. 22, 2009]. In this method, wires are passed through the radius, on which the distal support is mounted, and the proximal support of the Ilizarov apparatus is installed on the wires passed through the ulna. In the area of fused fragments of the ulna, an oblique osteotomy is performed, intraosseous threaded rods are introduced into the resulting fragments, perpendicular to each of them, and they are installed on remote brackets mounted on the supports of the Ilizarov apparatus. Through the upper third of the radius, in the ulnar direction, a pin with a thrust platform is passed, and it is fixed in a distraction rod with a groove on the proximal support remote bracket. The shortening of the ulna is eliminated, and the interosseous membrane is tensioned due to the formation of a curved distraction regenerate, at the same time, the dislocation of the head of the radius is gradually reduced with a pin with a thrust platform. However, the use of intraosseous threaded rods involves the use of rods with a diameter of 3 mm in children, which have a shallow cut, which in practice is fraught with their tearing out, and in some cases, a fracture of the ulna at the sites of their insertion during the formation of a bone regenerate of the ulna with an angle open towards the radius. bones. In addition, the use of open osteotomy is traumatic, accompanied by a displacement of the fragments relative to each other in width, which negatively affects the formation of distraction bone regenerate, and prolongs the patient's treatment time.

The essence of the invention lies in the combination of essential features sufficient to achieve the desired technical result, which consists in reducing the trauma of the intervention, improving the anatomical and functional outcomes of treatment, while reducing its time.

The essence of the method for the treatment of chronic fracture-dislocation of Monteggia includes the imposition of a two-section external fixation device (AVF), violation of the integrity of the ulna in the area of its fused fragments, restoration of the interosseous gap, and reversal of the head of the radius until the tension of the interosseous membrane. Intramedulyarno spend the needle in the ulna. The radiograph determines the true value of the shortening of the ulna relative to the radius, and the top of the deformity formed by fused fragments of the ulna. Percutaneously produce osteoperforation at the top of the angular deformity of the ulna, and its subsequent closed osteoclasis. The distal annular support of the AVF is mounted through outriggers on two Kirschner wires, passed crosswise through the distal parts of the radius and ulna, on the wire, passed through the proximal part of the ulna, through the outboard brackets, the proximal annular support of the AVF is fixed. A pin with a thrust pad is inserted perpendicular to the radius in its upper third in the ulnar direction, and fixed in a distraction rod with a groove on an external bracket mounted on the proximal support of the AVF. Through the proximal end of the distal fragment of the ulna, a second pin with a thrust platform is passed, and it is fixed on the distal support of the apparatus through an external bracket in the distraction rod with a groove. Perform primary distraction. After 5-6 days, distraction and formation of the bone regenerate of the ulna begins by moving the nuts along the threaded rods connecting the annular supports of the apparatus. The formation of a curved distraction regenerate is carried out by moving the nut on the mentioned external standard bracket, which fixes the spoke with the thrust pad on the distraction rod with a groove mounted on the distal annular support of the AVF. At the same time, distraction is performed with nuts along the AVF threaded rods. The dislocation of the head of the radius is reduced by moving the pin with the thrust pad fixed in the distraction rod with a groove mounted on the bracket of the proximal annular support. After X-ray control, the apparatus is stabilized for 6 weeks. The wire is removed intramedullary 2-3 weeks after the regenerate bone reconstruction.

Mounting of the distal annular support of the AVF on two Kirschner wires, passed crosswise through the distal parts of the radius and ulna, makes it possible to exclude the mobility of the annular support.

Fixation of the second annular support of the AVF on the pin, passed through the proximal part of the ulna, ensures the stability of this support, since the pin is held intramedullary, and the pin with the thrust pad is perpendicular to the radius, creates a spatial decussation.

Determination of the true value of the shortening of the ulna relative to the radius from the radiograph is necessary to determine the size of the formed distraction bone regenerate.

Insertion of a pin with a thrust pad perpendicular to the proximal end of the distal fragment of the ulna, and fixing it in a distraction rod with a groove on an external bracket fixed on the distal support of the device, ensures the formation of a curved bone regenerate with an angle open to the radial side. In this case, the tension of the interosseous membrane occurs, reduction and, subsequently, retention of the head of the radius.

Intramedullary insertion of the pin into the ulna prevents displacement and ensures a stable ratio of bone fragments during its lengthening and the formation of a curved regenerate.

Percutaneous osteoperforation at the apex of the angular deformity of the ulna provides closed osteoclasia, which, compared to open osteotomy, is less traumatic and allows for lengthening of the ulna while maintaining nutrition of the area of the formed distraction regenerate of the ulna.

Passing through the upper third of the radius, in the ulnar direction, the second spoke with a thrust platform, and fixing it in the distraction rod with a groove on the bracket mounted on the proximal support of the apparatus, allows, if necessary, to correct, tighten the head of the radius to the articular notch of the ulna .

Primary distraction along the rods connecting the AVF supports, performed immediately after applying the device and inserting all the wires in the operating room, allows us to assess the quality of the performed closed osteoclasia and the amount of diastasis between the fragments in the area of osteoclasia.

Subsequent distraction, and the formation of a distraction regenerate by the amount of relative shortening of the ulna with an angle open to the radial side, ensures the reduction of the head of the radius and its retention due to the tension of the interosseous membrane.

The method is illustrated by the illustrations.

In FIG. 1 shows the forearm before surgery, where: 1 - radius; 2 - ulna, fragments of which are fused at an angle with apex 3, directed to the radial side; 4 - intramedullary wire through the ulna, 5 - cross wires through the distal radius and ulna, on which the distal annular support of the AVF is mounted (not shown); 6 - a pin passed through the proximal ulna, on which the second annular support of the AVF (not shown) is fixed on external brackets; 7 - head of the radius; 8 - a pin with a thrust pad, drawn perpendicular to the proximal end of the distal fragment of the ulna, and fixed in a distraction rod with a groove on an external bracket mounted on the distal support of the apparatus (not shown); 9 - second pin with a thrust pad, passed through the upper third of the radius, in the ulnar direction, fixed in a distraction rod with a groove on an external bracket mounted on the proximal support of the AVF (not shown); 10 - the line of the planned osteoclasia at the top of the deformity of the ulna; 11 - osteoperforation at the top of the angular deformity of the ulna; 12 - distraction regenerate of the ulna.

In FIG. 2 shows the forearm after the operation, where: the ulna 3 is elongated due to the formed curved distraction regenerate 12 with an angle open to the radial side; head 7 of the radius 1 in a state of reduction.

In FIG. 3 - fig. 6 shows x-rays of patient S., 7 years old (see clinical example):

In FIG. 3 - before surgery;

In FIG. 4 - 3 weeks after surgery in the AVF;

In FIG. 5 - after dismantling the AVF;

In FIG. 6 - 4 weeks after the removal of the intramedullary wire.

The method of treatment of chronic fracture-dislocation of Montage is carried out as follows.

After treatment of the skin through the distal ulna - 2 wire 4 is intramedullary to the proximal metaphysis. The radiograph determines the true value of the shortening of the ulna relative to the radius, and the top of the deformity formed by fused fragments of the ulna. Percutaneously produce osteoperforation 3 of the ulna 2, at the top of the angular deformity, and its closed osteoclasis. Through the distal section of the radius 1 and ulna 2, two Kirschner wires 5 are passed crosswise and the distal annular support of the external fixation apparatus (not shown) is mounted on outboard brackets. Through the proximal part of the ulna, a Kirschner wire 6 is passed, on which the proximal annular support of the AVF (not shown) is fixed through outriggers. AVF ring supports are connected using threaded rods. Radiologically and clinically, the top of the deformity formed by fused fragments of the ulna 2 is determined. Through the proximal end of the distal fragment of the ulna, a pin 8 with a thrust platform is inserted perpendicular to the fragment of the ulna 2, which is fixed in a distraction rod with a groove and mounted on an external standard bracket, fixed on the distal annular support of the device. Through the upper third of the radius 1, in the ulnar direction, a second pin with a thrust platform 9 is passed, and it is fixed on a distraction rod with a groove through an external bracket mounted on the proximal annular support of the AVF. Perform primary distraction. After 5-6 days, distraction and formation of the bone regenerate 12 of the ulna 2 begins, by moving the nuts along the threaded rods connecting the annular supports of the apparatus. The formation of a curved distraction regenerate 12 is carried out by moving the nut of the distraction rod with a groove that fixes the spoke 8 with a thrust pad. At the same time, distraction is performed with nuts along the threaded rods of the AVF annular supports. These manipulations make it possible to eliminate the shortening of the ulna 2 and to stretch the interosseous membrane. At the same time, the dislocation of the head 7 of the radius 1 is gradually reduced by moving the spoke 9 with the thrust pad fixed in the rod with a groove through the remote bracket of the proximal annular support of the AVF. After X-ray control, the apparatus is stabilized for 6 weeks and then dismantled. The intramedullary wire is removed 2-3 weeks after the regenerate bone reconstruction. Assign a course of physiomechanotherapy.

Clinical example

Patient S., 7 years old, was admitted on 07/09/2019 with a diagnosis of chronic Montage fracture (Fig. 3). On July 11, 2019, the operation was performed: Closed osteoclasia of the ulna of the left forearm with the imposition of AVF (Fig. 4).

After treatment of the skin, through the distal ulna, intramedullary, a pin was passed to the proximal metaphysis. According to the radiograph, the true value of the shortening of the ulna relative to the radius, and the apex of the deformity formed by fused fragments of the ulna were determined. Percutaneous osteoperforation of the ulna was performed at the apex of the angular deformity and its subsequent closed osteoclasis. Through the distal sections of the radius and ulna, two Kirschner wires were passed crosswise, and the distal annular support of the external fixation apparatus was mounted on the outriggers. A Kirschner wire was passed through the proximal part of the ulna, on which a proximal annular support was fixed through outriggers. AVF annular supports were connected using threaded rods. Radiologically and clinically, we determined the apex of the deformity formed by fused fragments of the ulna. Through the proximal end of the distal fragment of the ulna, a pin with a thrust platform was inserted perpendicular to the fragment of the ulna, which was fixed on a distraction rod with a groove, and mounted on an external bracket fixed on the distal annular support of the apparatus. Through the upper third of the radius, in the ulnar direction, a second pin with a thrust platform was passed, and it was fixed on a distraction rod with a groove through an external bracket mounted on the proximal annular support of the AVF. Performed primary distraction. After 5 days, distraction began, and the formation of a bone regenerate of the ulna, by moving the nuts along the threaded rods connecting the apparatus supports. The formation of a curved distraction regenerate was performed by moving the nut of the distraction rod with a groove fixing a pin with a thrust pad, passed through the proximal end of the distal fragment of the ulna, fixed through the outrigger of the distal annular support of the AVF. At the same time, distraction was performed with nuts along the AVF threaded rods. These manipulations made it possible to eliminate the shortening of the ulna, restore the interosseous space, and stretch the interosseous membrane. Simultaneously, the gradual reduction of the dislocation of the head of the radius was performed by moving the pin with the thrust platform, passed through the upper third of the radius, in the ulnar direction and fixed in the distraction rod with a groove, through the remote bracket of the proximal annular support of the AVF. After X-ray control, the device was stabilized, and after 6 weeks it was dismantled (Fig. 5), the intramedullary wire was left for 3 weeks, after the time had elapsed it was removed (Fig. 6). The patient was discharged, she was prescribed a course of physiomechanotherapy.

Claims (1)

A method for the treatment of chronic fracture-dislocation of Monteggia, including the imposition of a two-section external fixation device (AVF), disruption of the integrity of the ulna in the area of its fused fragments, restoration of the interosseous space and reversal of the head of the radius to the tension of the interosseous membrane, characterized in that the needle is inserted intramedullary into the ulna, according to the radiograph, the true value of the shortening of the ulna relative to the radius and the apex of the deformity formed by fused fragments of the ulna are determined, percutaneously, osteoperforation is performed at the apex of the angular deformity of the ulna and its subsequent closed osteoclasis, the distal annular support of the AVF is mounted through external brackets on two Kirschner wires, carried out crosswise through the distal sections of the radius and ulna, on the needle, passed through the proximal section of the ulna, through the outriggers, the second annular support of the AVF is fixed, the needle is inserted with a thrust platform perpendicular to proximal fragment of the ulna, and fix it on a distraction rod with a groove on the remote bracket, fixed on the proximal support of the apparatus, through the proximal end of the distal fragment of the radius, in the ulnar direction, pass the second pin with a thrust platform and fix it on the distal support of the apparatus through remote bracket in the distraction rod with a groove, primary distraction is performed, after 5-6 days, distraction and the formation of the bone regenerate of the ulna begin by moving the nuts along the threaded rods connecting the apparatus supports, the formation of a curved distraction regenerate is performed by moving the nut on the mentioned external standard bracket fixing the spoke with a thrust platform on the distal annular support of the AVF, with simultaneous distraction with nuts along the threaded rods of the AVF, the dislocation of the head of the radius is reduced by moving the second pin with a thrust platform, after X-ray control, the device is stabilized for 6 weeks, intramedulla The lar wire is removed 2-3 weeks after the regenerate bone reconstruction.

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