RU2786821C1 - Method for surgical treatment of post-traumatic flexion contracture of the finger at the level of the proximal interphalangeal joint - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to hand surgery, and can be used for surgical treatment of post-traumatic flexion contracture of the finger at the level of the proximal interphalangeal joint (PIPJ). The palmar plate is accessed, the damaged finger is redressed, and the PIPJ is fixed with a splint. U-shaped access is performed along the palmar surface of the main and middle phalanges, the skin-fat flap is isolated and raised, the neurovascular bundle is isolated, it is shifted, the palmar plate is isolated, its ligaments are differentiated, located 3 mm proximal to the PIPJ. Focusing on the transverse digital artery, the palmar plate is dissected at the level of its ligaments. PIPJ is redressed with the elimination of contracture. The branches extending from the digital artery to the fatty tissue of the palmar surface of the damaged finger are identified, a vascularized fat flap is isolated, it is passed under the deep flexor tendon in the defect of the palmar plate and fixed in the recipient zone with U-shaped sutures. The wound is sutured, the proximal interphalangeal joint is fixed with a splint. When tenogenic contracture is detected, flexor tenolysis is performed with dissection of the collateral ligaments.

EFFECT: method provides increasing the range of motion of the injured finger, reducing the time of immobilization of the finger, preventing the recurrence of flexion contractures and reducing the time of treatment due to palmar plasty.

2 cl, 6 dwg, 1 ex

Description

The invention relates to medicine, specifically to hand surgery, and is used in the surgical treatment of flexion contractures at the level of the proximal interphalangeal joint.

There are many reasons for the formation of flexion contractures at the level of the proximal interphalangeal joint (PMJJ), however, usually the cause is the pathology of the palmar plate and its lateral processes, which normally prevent joint hyperextension. It is well known that the proximal interphalangeal joints are prone to the formation of flexion contractures. The most common flexion contractures of the PMFJ in cases of damage to the palmar plate occur after immobilization in a bent position, reduction of dislocations, or in the presence of fractures in the PMFJ area.

A known method for the treatment of post-traumatic contractures of the fingers at the level of the proximal interphalangeal joint [RF patent No. 2138218 A61V 17/56, 1999], which includes several stages. An external fixation device is applied, and on day 2-3, after the pain subsides, distraction is started in a slow mode, 1 mm per day until the flexion contracture is eliminated, and then by 2πR⋅d/360°. The patient, in order to prevent scarring of the deep flexor tendon with the palmar plate in the process of distraction, performs active-passive movements with a load in the PMFS, aimed at bending the nail phalanx. In a stretched state, the finger is fixed in the apparatus for 12-21 days, the apparatus is removed, and intensive development of movements in the affected joint is carried out. The patient continues to engage in active-passive gymnastics aimed at maximum flexion of the nail phalanx. After removing the apparatus, intensive development of movements in the affected joint is carried out.

The disadvantages of this method are:

1. severe pain syndrome;

2. the presence of an external fixation device, and its long-term wearing, the need for dressings. The risks of pin infection are higher the longer the external fixator is used;

3. restriction of the patient's physical activity for several months;

4. postoperative complications, pin suppuration, contracture recurrence

The closest, in its technical solution, is adopted by us for the prototype method of surgical treatment of flexion contractures of the fingers at the level of PMFS [The treatment of chronic flexion contractures of the proximal interphalangeal joint G. Abbiati, G. Delaria, E. Saporiti, M. Petrolati and C. Tremolada Journal of Hand Surgery (British and European Volume, 1995) 20B: 3:385-389]. From the lateral access, at the level of the PMFS, dissection of additional collateral ligaments, sheaths of the flexor tendon, excision of the palmar plate and its lateral processes is performed. Next, redress the injured finger. To maintain the achieved position, the joint is fixed with a functional splint. This method is widely used in the treatment of flexion contractures, but the results of treatment remain unsatisfactory in 42% of cases. The disadvantage of this method is repeated (recurrent) scarring of the deep flexor of the finger at the level of the proximal interphalangeal joint due to the formation of a defect at the site of the excised palmar plate, requiring repeated operations in 31% of cases. [Long-term results of surgical management of proximal interphalangeal joint contracture Sean D Ghidella 1, Keith A Segalman, Mary Schuler Murphey J Hand Surg Am. 2002 Sep; 27(5):799-805. doi: 10.1053/jhsu.2002.3530].

The essence of the invention is expressed by a set of essential features sufficient to achieve the desired technical result, which consists in increasing the range of motion of the injured finger, reducing the time for immobilization of the finger, preventing the recurrence of flexion contractures, while reducing the treatment time.

The essence of the method of surgical treatment of post-traumatic flexion contracture of the finger at the level of the proximal interphalangeal joint includes access to the palmar plate, redressing the injured finger, and fixing the PMFS with a splint. U-shaped access is performed along the palmar surface of the main and middle phalanges, the skin-fat flap is isolated and lifted. Allocate the neurovascular bundle, shift it. The palmar plate is isolated, its ligaments are differentiated, located 3 mm proximal to the PMPS. Focusing on the transverse digital artery, the palmar plate is dissected at the level of its ligaments, the PMFS is redressed with the elimination of contracture. Branches extending from the digital artery to the fatty tissue of the palmar surface of the injured finger are identified. A vascularized fat flap is isolated, passed under the deep flexor tendon in the defect of the palmar plate, and fixed in the recipient zone with U-shaped sutures. The wound is sutured, the proximal interphalangeal joint is fixed with a splint for 2 weeks.

If the contracture persists, tenolysis of the flexors is performed with dissection of the collateral ligaments.

The use of U-shaped access along the palmar surface of the main and middle phalanges improves the visualization of PMPS.

The isolation and elevation to the opposite side of the skin-fat flap provides the possibility of obtaining a wide access to the PMFS and determining the vessels present in the adipose tissue, which makes it possible to isolate the blood-supplying fat flap.

Isolation of the neurovascular bundle, and its shift, ensures the safety of this bundle during manipulations.

Isolation of the palmar plate, differentiation of its ligaments, located 3 mm proximal to the PMFS, with an orientation towards the presence of the transverse digital artery, avoids damage to the artery, and makes sure that we are at the level of the transition of the plate to its ligaments.

Dissection of the palmar plate at the level of its ligaments, followed by joint redressing, eliminates the contracture.

Identification of the branches extending from the digital artery to the fatty tissue of the palmar surface of the injured finger, and isolation of the vascularized fat flap, allows preserving the blood supply to the adipose tissue, improving its engraftment, preventing its necrosis and cicatricial degeneration.

Passing the flap under the deep flexor tendon in the defect of the palmar plate, and fixing it in the recipient zone with U-shaped sutures, eliminates the sagging of the deep flexor tendon over the defect zone, eliminates chaotic scarring of the area of the formed defect, eliminates the fusion of the flexor tendon with the joint capsule, preventing contracture recurrence .

Fixation of the proximal interphalangeal joint with a splint for 2 weeks ensures the preservation of function in the joint until the wounds are completely healed, and ensures the prevention of postoperative complications: suture failure, necrosis of the fat flap.

Performing tenolysis of the flexors with dissection of the collateral ligaments eliminates tenogenic contracture.

The method is illustrated by intraoperative photos for a clinical example, where:

In FIG. 1 - photo of patient X.'s hand before surgery;

In FIG. 2 - U-shaped access along the palmar surface of the main and middle phalanges of the finger, with the release of a skin-fat flap;

In FIG. 3 - dissected palmar plate;

In FIG. 4 - isolation of a vascularized fat flap;

In FIG. 5 - carrying out a fat flap under the tendon of the deep flexor in the defect of the palmar plate;

In FIG. 6a, fig. 6b - sutured wound.

The method is carried out as follows.

Under local anesthesia, a U-shaped access is performed along the palmar surface of the main and middle phalanges, a skin-fat flap is isolated and lifted. Allocate the neurovascular bundle, shift it. The palmar plate is isolated, its ligaments are differentiated, located 3 mm proximal to the PMFS, focusing on the transverse digital artery. The palmar plate is dissected at the level of its ligaments, the PMFS is redressed with the elimination of contracture. The branches extending from the digital artery to the fatty tissue of the palmar surface of the damaged finger are identified, a vascularized fat flap is isolated, passed under the deep flexor tendon in the palmar plate defect, and fixed in the recipient zone with U-shaped sutures. The wound is sutured, the proximal interphalangeal joint is fixed with a splint for 2 weeks.

If the contracture persists, tenolysis of the flexors is performed with dissection of the collateral ligaments.

Clinical example.

Patient X., aged 60, complained of limited extension of the 4th finger of the left hand. He received an injury 4 months before treatment as a result of a heavy object falling on his arm. He was treated conservatively in the emergency room at the place of residence, where he underwent x-rays, plaster immobilization for 10 days. After the termination of immobilization, he noted a decrease in edema, the preservation of minor pain, while flexion contracture gradually developed. Received physiotherapy treatment, without success.

Examination revealed the presence of flexion contracture of the 4th finger PMFS, active and passive movements: flexion 90°, extension 120°. Instability in PMFS was not revealed. Movement in the metacarpophalangeal and distal interphalangeal joints in full. Vascular and neurological deficit was not revealed.

Concomitant diseases: hypertension 1 degree. Systemic connective tissue diseases were not identified. Heredity is not burdened. There are no bad habits. Works as a locksmith.

Patient X. underwent surgery as described above. Under local anesthesia, U-shaped access along the palmar surface of the main and middle phalanges, the skin-fat flap was isolated and raised. The neurovascular bundle was isolated and displaced. The palmar plate was isolated by differentiating its ligaments located 3 mm proximal to the PMFS, focusing on the transverse digital artery. The palmar plate was dissected at the level of its ligaments, the PMFS was redressed with the elimination of contracture. The branches extending from the digital artery to the fatty tissue of the palmar surface of the injured finger were identified, a vascularized fat flap was isolated, passed under the deep flexor tendon in the defect of the palmar plate, and fixed in the recipient zone with U-shaped sutures. The wound was sutured, the proximal interphalangeal joint was fixed with a splint for 2 weeks.

After the operation, the patient received dressings. Tire metered movements started. For a period of 2 weeks, immobilization was discontinued, then he received physiotherapy treatment, and was engaged in physiotherapy exercises. At a period of 5 weeks, with a full range of active and passive movements, the patient returned to work.

Claims (2)

1. A method for surgical treatment of post-traumatic flexion contracture of the finger at the level of the proximal interphalangeal joint (PMJJ), including access to the palmar plate, redressing the injured finger and fixing the PMJ joint with a splint, characterized in that the U-shaped access is performed along the palmar surface of the main and middle phalanges, the skin-fat flap is isolated and lifted, the neurovascular bundle is isolated, shifted, the palmar plate is isolated, its ligaments are differentiated, located 3 mm proximal to the PMFS, focusing on the transverse digital artery, the palmar plate is dissected at the level of its ligaments, the PMFS is redressed with elimination of the contracture, the branches extending from the digital artery to the fatty tissue of the palmar surface of the injured finger are identified, a vascularized fat flap is isolated, it is passed under the tendon of the deep flexor in the defect of the palmar plate and fixed in the recipient zone with U-shaped sutures, the wound is sutured, the proximal interfacial the langiar joint is fixed with a splint. 2. The method according to claim 1, characterized in that when tenogenic contracture is detected, flexor tenolysis is performed with dissection of the collateral ligaments.

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