RU2775885C1 - Method for osteosynthesis of sub-capital fractures of metacarpal bones - Google Patents

Abstract

FIELD: medicine; traumatology; orthopedics.

SUBSTANCE: invention relates to medicine, in particular to traumatology and orthopedics; it can be used for the treatment of sub-capital fractures of metacarpal bones with the displacement of fragments. After performing a closed manual reposition, two channel bones running in parallel along the axis of the metacarpal bone are formed, into each of which a biodegradable rod structure is inserted, so that its end reaches the bottom of the corresponding formed channel in the head of the metacarpal bone.

EFFECT: method provides for stable fixation of fragments of the metacarpal bone and favorable conditions for bone tissue regeneration, prevents repeated displacement, allows for maintenance of an articular cartilage and prevention of the possibility of following arthrosis of a metacarpophalangeal joint, as well as allows for avoidance of the development of postoperative contractures of the metacarpophalangeal joint and reduction in the risk of development of purulent-septic complications due to a set of techniques of the claimed invention.

1 cl, 5 dwg, 1 ex

Description

The invention relates to medicine, in particular to traumatology and orthopedics, and can be used to treat subcapital metacarpal fractures with fragment displacement.

The treatment of fractures of the metacarpal bones, due to the high frequency of these injuries and the high functional requirements for the hand, is one of the most important problems in traumatology and orthopedics. Fractures of the metacarpal bones account for up to 40% of the total number of all fractures of the upper limb. Of these, the displacement of bone fragments is observed in 54.7% [1,2].

A known method for fixing a fracture of the long bones of the hand (RU2718270, C1) [3], which can be used in the surgical treatment of transverse, oblique, intraarticular, spiral and other unstable fractures of the tubular bones of the hand, which provides early recovery of the full function of the hand and stable fixation of the metaepiphyseal area. fractures of the tubular bones of the hand due to osteosynthesis with a pin that retains its plasticity. The method involves the use of a wire for osteosynthesis, a part of which is fired before being inserted into the bone, followed by cooling to a temperature that preserves the plasticity of the wire material, but does not destroy the bone tissue. Processing is subjected to a predetermined length of the part of the spoke, which is determined taking into account the fact that after installing the processed part into the bone, it should protrude outward from both sides. After that, the needle with the unburned end is inserted into the bone, passed through the fragments and the fracture line, and the treated part is placed in the bone. The unburned part of the needle is bitten off, and the ends of the processed part of the needle, protruding from the bone, are bent.

The disadvantages of this method are: the need for additional equipment for heating, the complexity of determining the optimal temperature of the needle; the possibility of rotation of fragments due to the use of only one wire when performing osteosynthesis, the risk of infectious complications, the need to remove the metal structure (pins).

A known method of fixing a fracture of the tubular bones of the hand (RU 2555391, C1) [4], which involves the implementation of transarticular osteosynthesis with a pin to the level of the lower third of the main phalanx of the finger. The method is used for comminuted, spiral fractures, where the bone is held by one Kirschner wire. A Kirschner wire is passed through the base of the metacarpal bone into its canal to the level of the fracture. A closed reposition of the fracture and its fixation are performed by further passing the pin through the head of the damaged bone to the level of the lower third of the main phalanx of the fifth finger of the hand. The wound is sutured. After 3 weeks, the pins are removed with the same access after X-ray control, then therapeutic exercises are performed.

The disadvantages of this method are: the risk of migration of metal structures; transarticular position of the stabilizing pin, which excludes the function of the metacarpophalangeal joint and can lead to contracture in the late postoperative period; the end of the wire left on the skin surface can cause purulent-septic complications, the need for repeated intervention in order to remove the fixing wire.

There is a method for intramedullary osteosynthesis of the metacarpal bone (RU2676463 C1) [5], in which the fragments are repositioned, and for osteosynthesis a wire is used, modeled by double bending it along its length to form three parts. In this case, the length of the middle part should correspond to the length of the medullary canal of the damaged metacarpal bone. One of the end parts should be shorter than the middle part by 1-2 mm. The other end part should be 3-5 mm longer than the middle part. In the projection of the base of the metacarpal bone on the dorsum of the hand, a skin incision of 1.5-2.5 cm is made. Through the base of the metacarpal bone, its bone marrow canal is reamed along the entire length to a diameter that makes it possible to pass through it a simulated threefold knitting needle. A simulated pin is passed through the formed expanded bone marrow canal from the side containing the free end of the shortened end part to the level of the fracture. Perform a closed reposition of fragments. The simulated pin is advanced to the level of the metacarpophalangeal joint. The free end of the elongated end portion is bent at a 90° angle and driven into the metacarpal bone.

The disadvantages of this method are: the need to perform a surgical incision for the reposition of fragments, which increases the trauma of surgery; complex modeling of the spoke during its installation; the risk of metallosis as a result of the intramedullary location of the metal structures along the length of the entire metacarpal bone; the risk of infectious complications; the need for repeated intervention to remove the metal structure.

Closest to the claimed is a method of retrograde osteosynthesis of subcapital fractures of the metacarpal bone [6], in which the fragments after reposition are fixed with a temporary needle passed through the head of the metacarpal bone. Then, using a drill through pre-formed punctures in the area of the head of the metacarpal bone, two bone canals are formed with a depth to the border of the middle and proximal thirds of the metacarpal bone, into which one biodegradable rod structure (hereinafter, pins) with a diameter of 2.0 mm is inserted. In this case, the pins are introduced subcortically relative to the articular surface of the metacarpal head. The operation ends with the removal of the temporary fixing needle.

The disadvantages of this method are: additional manipulations for holding the fixing pin after repositioning bone fragments, which increases the time of the operation, as well as performing arthrotomy and conducting biodegradable pins through the articular surface of the metacarpal head, which can lead to the formation of contracture of the metacarpophalangeal joint and its subsequent development. arthrosis.

This operation is the prototype of our proposed method.

The technical result of the invention is to provide conditions for the consolidation of a fracture of the metacarpal bone, the prevention of arthrosis and contractures of the metacarpophalangeal joint, as well as reducing the risk of purulent-septic complications and the absence of the need for repeated surgical intervention to remove the fixators.

The result is achieved due to the fact that after performing a closed manual reposition, two bone channels parallel to the axis of the metacarpal bone are formed, and the channels are formed from the base of the metacarpal bone to the inner surface of the cortical layer of the metacarpal head, into which one biodegradable rod structure is inserted so that its end reached the bottom of the corresponding formed canal in the metacarpal head.

The formation of bone canals from the base of the metacarpal bone to its head to the inner surface of the cortical layer and, accordingly, passing one biodegradable pin into the formed canals allows for stable fixation of metacarpal bone fragments, prevents secondary displacement and provides favorable conditions for bone tissue regeneration. At the same time, the pins are inserted into the formed channels up to the inner surface of the cortical layer of the metacarpal head, without crossing its articular surface, which allows preserving the metacarpophalangeal joint and, accordingly, restoring the function of the hand within the established medium terms and without negative consequences associated with damage to the joint.

Antegrade conduction of the pins, that is, their introduction through the formed channels from the base of the metacarpal bone in the distal direction, ensures the preservation of the articular cartilage of the metacarpophalangeal joint and the prevention of possible subsequent arthrosis of the metacarpophalangeal joint.

In addition, this method of forming channels and inserting biodegradable constructs in them makes it possible to avoid arthrotomy of the metacarpophalangeal joint and, therefore, preserve the extensor apparatus of the corresponding finger, which is a prevention of the development of postoperative contractures of the metacarpophalangeal joint.

Another advantage of this technique is to reduce the risk of purulent-septic complications, since the pins are carried out at a greater distance from the fracture site (several centimeters) than with retrograde injection (several millimeters).

In addition, the exclusion of the pin insertion stage allows to reduce the time of osteosynthesis, and the use of biodegradable structures in this method of osteosynthesis eliminates the need for repeated surgical intervention to remove the fixators.

The illustrations show (on the example of the second metacarpal bone):

Fig.1. - Scheme of the process of reposition of fragments of the metacarpal bone, where: 1 - the state of the bone fragments of the metacarpal bone after the elimination of angular displacement and displacement along the length; 2- traction of the second finger along the axis;

Fig.2.- Scheme of operational access to the base of the metacarpal bone, where: 3- two cuts of 0.5 cm in the area of the base of the metacarpal bone;

Fig.3.- Diagram of the formation of one of the two parallel channels of the metacarpal bone, where: 4 - drill; 5 - intraosseous canal to the depth of the cortical layer of the metacarpal head;

Fig.4. - Installed biodegradable structures in the formed channel (scheme, side view), where: 6 - impactor, removed from the wound after installing the biodegradable pin; 7 - biodegradable pin in the formed metacarpal canal;

Fig.5. - Installed biodegradable structures in the formed channels (diagram, top view), where: 6 - impactor, removed from the wound after the installation of the biodegradable pin; 7 - biodegradable pins in the formed metacarpal canals.

The method is carried out as follows: the position of the patient on the operating table on the back, the hand is located on the application table. The upper limb is treated three times with antiseptic solutions from the nail phalanges to the upper third of the shoulder. Under conduction anesthesia of the upper limb produce a closed manual reposition of the fracture of the metacarpal bone by traction for the finger while fixing the metacarpophalangeal joint in the flexion position of 90 degrees (Figure 1). Next, x-ray control is performed in frontal and lateral projections to determine the quality of fragment reposition. Then, with a pointed scalpel in the projection of the base of the metacarpal bone, two symmetrical incisions 0.5 cm long are performed (Figure 2). Through these pre-formed accesses along the long axis of the metacarpal bone, parallel to each other, using a drill with a diameter of 1.8 mm and under image intensifier control, two intraosseous channels are formed, extending to the inner surface of the cortical layer of the metacarpal head (Figure 3). Next, a biodegradable pin with a diameter of 2.0 mm and a length of 0.5 cm less than the length of the metacarpal bone is placed in the impactor so that the distal pin stands 1 cm from the edge of the impactor. The part of the pin protruding from the impactor is placed in the opening of one of the previously formed channels, while the impactor is inserted into the formed access to the beginning of the said channel and placed strictly along the axis of the metacarpal bone. Using an orthopedic hammer by tapping on the handle of the impactor, the pin is advanced in the distal direction along the formed channel in the bone to its entire depth (Figure 4). After contact of the pin with the inner surface of the cortical layer of the head of the metacarpal bone, the impactor is removed. The implantation of the second pin in another formed channel is performed according to a similar technique (Figure 5).

The operation is completed with a repeated image intensifier tube control, a check of passive movements in the metacarpophalangeal joint, and the application of an aseptic bandage. Immobilization of the operated segment is performed with a plaster splint from the main phalanges of the operated and two adjacent rays to the middle third of the forearm. In this case, movements are possible in the distal and proximal interphalangeal joints of the corresponding finger of the hand. The terms of plaster immobilization are 4 weeks, after which X-ray control is performed and rehabilitation begins.

The presented clinical observation demonstrates the versatility of the method and the possibility of its application for the treatment of subcapital fractures of any metacarpal bones.

Patient K., 26 years old, was admitted to the clinic of R.R. Damaged on 10/25/18 with a diagnosis of closed subcapital fracture of the 5th metacarpal bone of the right hand with displacement of fragments. On October 25, 2018, osteosynthesis of the fracture with biodegradable pins was performed: under conduction anesthesia, a closed reposition of the fragments was performed, after which X-ray control was performed to assess the quality of the reposition. Next, surgery performed according to the proposed method. The operation time was 10 minutes. The postoperative period is smooth. The wounds healed by first intention. Consolidation of fragments occurred after 4 weeks, after which rehabilitation treatment was carried out (a course of exercise therapy, physiotherapeutic procedures). When viewed after 6 weeks, the pain syndrome was stopped, the range of motion in the joints of the fingers was complete. Achieved excellent aesthetic and functional results.

The above clinical example was presented in order to illustrate the application of the method and is not exhaustive: it is also possible to use the proposed method in osteosynthesis of subcapital fractures of other metacarpal bones, thereby presenting an opportunity for specialists in the art to understand the sequence of actions of the method and apply it in each specific clinical case.

Bibliography

1. Warwick D. at al. Oxford Specialist Handbooks in Surgery Hand Surgery 2013. P. 149-159.

2. Charles S. Day. Green's Operative Hand Surgery. 7th ed. 2017. Ch. 7. P. 231-27

3. Pat. 2019139369 RF, IPC A61B 17/72. A method for fixing metaepiphyseal fractures of the tubular bones of the hand. Egiazaryan K.A., Korshunov V.F., Kazakov K.A. ; dec. 04.12.2019; publ. 04/01/2020 Bull. No. 10.

4. Pat. 2014114451/14 Russian Federation, IPC A61B 17/56. A method for treating a fracture of the v metacarpal bone of the hand. Guryev V.V., Sklyanchuk E.D., Zorya V.I., Ivkin S.I., Prosvirin A.A.; dec. 04/14/2014; publ. 07/10/2015 Bull. No. 19

5. Pat. 2018123017 RF, IPC A61B 17/56, A61B 17/58. The method of surgical treatment of metaepiphyseal fracture of the metacarpal bone. Egiazaryan K.A., Korshunov V.F., Kazakov K.A.; dec. 06/25/2018; publ. : 28.12.2018 Bull. No. 1

6. https://www.youtube.com/watch?v=eqtr8Bo0aTs

Claims (1)

A method for osteosynthesis of subcapital fractures of the metacarpal bones, including closed reposition of bone fragments and fixation with biodegradable rod structures passed through two formed parallel bone channels, characterized in that these channels are formed from the base of the metacarpal bone to the inner surface of the cortical layer of the head of the metacarpal bone and lead into them along one biodegradable rod structure so that its end reaches the bottom of the corresponding formed channel in the metacarpal head.

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