RU2248179C2 - Method for diagnosing acute tissular hypertension syndrome in forearm bone trauma cases - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves synchronously recording intratissular pressure of injured and healthy forearm muscles. Percent from difference3 of the values is calculated and closed forearm fracture development course aggravated with acute tissular hypertension syndrome is predicted, when increase in 30 % or higher takes place.

EFFECT: high accuracy in diagnosing syndrome manifestations.

2 dwg

Description

The invention relates to medicine, namely to diagnostic methods, and can be used in traumatologists and surgery for the operational diagnosis of acute tissue hypertension syndrome, as complications of fractures of the forearm bones.

Tissue hypertension syndrome is one of the most common complications of closed injuries of long tubular bones. In foreign literature, this pathological process is known as compartment syndrome, and is defined as a condition in which increased interstitial pressure in an enclosed space leads to damage to neuromuscular structures located inside this space (1).

The pathogenesis of acute tissue hypertension syndrome has been studied quite well. It was established (2) that the wall of a vein (venule) of a large circle of blood circulation is 6-10 times more flexible than the wall of an artery (arteriole). Transmural pressure for the venous section of the pulmonary circulation is 1.3-1.6 kPa, for arterial - 7.0-11.0 kPa, the tangential wall stress is 9-16 kPa for veins and venules, and 7-77 kPa for arteries, respectively and arterioles. Increased interstitial pressure, acting externally on the compliant wall of venous vessels passing in closed fascial cases, can cause a local increase in venous pressure due to an increase in hydrodynamic resistance. In this case, the local arteriovenous gradient decreases, and with it the regional blood flow. Due to the fact that the pressure inside the closed fascial case remains below the pressure in the arteries, the peripheral blood flow through the arteries passing through the case remains unchanged, therefore, the pulsation of the arteries at the periphery will be preserved, and normal distal arteriovenous gradient will be detected by capillaroscopy.

The pathogenesis of tissue hypertension syndrome is triggered by the following causes of increased interstitial pressure: bleeding into confined spaces, local increase in capillary permeability, which may be due to fractures of long tubular bones, osteotomies, soft tissue crushing, prolonged compression of the limb, postischemic edema that occurs after restoration of arterial blood flow. Further development of tissue hypertension syndrome is due to the cessation of venous outflow from muscles located in sealed fascial cases with high strength and elastic modulus with relatively small deformations. Iatrogenic factors contribute to the development of the compartment syndrome, namely circular soft and gypsum dressings, an excessively elevated position of the limb (above the level of the heart in a horizontal position). Late diagnosis and delayed medical care are the causes of the formation of myofascial pain syndromes observed in 70% of victims (3).

The following invasive methods are known (1), used to diagnose acute tissue hypertension syndrome, namely, the use of a needle gauge, a continuous infusion method, methods using lobe and wick catheters.

Common disadvantages of these methods are the inability to continuously monitor interstitial pressure in the affected segment and the invasiveness of the study. The critical value of interstitial pressure obtained by these methods, which, along with physical data, is an objective indicator of the validity of fasciotomy, varies depending on the measurement method.

The closest to the claimed invention in terms of essential features is a method for diagnosing decompensated extremity conditions during transosseous osteosynthesis (4), which allows to prevent possible complications and adjust patient management tactics in the process of restoring the anatomical integrity of the bone structure. A known method for the diagnosis of decompensated extremity conditions in transosseous osteosynthesis is to determine the peak blood flow index and compliance of the leg muscles. In accordance with the methodology of the method with peak blood flow index values less than 3.3 rel. units and compliance less than 3.0 × 10 ^-3 m / N diagnose the decompensated state of the muscles with acquired defects of the leg bones. Decompensated limb condition with peak blood flow index values of less than 1.3 rel. units and compliance less than 4.5 × 10 ^-3 m / N is diagnosed with congenital defects of the leg bones.

However, the prototype revealed a number of significant disadvantages:

- for the implementation of the method requires the presence of several diagnostic devices (electroplatysmograph, myotonometer), the calculations are made by a doctor;

- for the implementation of the method, it is also necessary to conduct a three-minute ischemic test and move the victim to the stomach, which excludes dynamic monitoring of the condition of the affected segment against the background of the general serious condition of the patient;

- from the above review it is clear that locus minoris resistentae in the development of tissue hypertension syndrome is the venous section of the microvasculature, and the prototype is designed to study the great vessels at the hip level;

- the prototype is not adapted for the diagnosis of tissue hypertension syndrome on the forearm.

The objective of the invention is to improve the results of surgical treatment of patients with closed fractures of the forearm.

The clinical result achieved by the implementation of the proposed method is the early detection of complications of injuries of the forearm.

The indicated clinical result is achieved by the fact that by non-invasively registering interstitial pressure, at which the interstitial pressure of the muscles of the affected and healthy forearm is synchronously recorded, a percentage of the difference in these values is calculated and the complicated course of the closed forearm fracture is predicted by acute tissue hypertension syndrome with an increase of 30% and more.

The drawings show electromyograms of the muscles of the forearms:

figure 1 - with timely diagnosis of acute tissue hypertension syndrome at various times before and after osteosynthesis;

figure 2 - with late diagnosis of acute tissue hypertension syndrome at various times before and after osteosynthesis.

The method is as follows.

On the injured and healthy forearm of the injured person in a horizontal position, rubber-fabric cuffs of the Gradient 4 device are applied (RF patent No. 2166905, 05.20.2001). The cuffs are fixed on symmetrical anatomical areas, the device is connected to the electrical network. After the apparatus is completed, the percentage ratio of the value of the interstitial pressure of a healthy and injured forearm is visualized on the indicator of an arithmetic logic device. Moreover, if the interstitial pressure in the injured forearm exceeds the interstitial pressure of a healthy forearm by 30% or more, the development of tissue hypertension syndrome is noted.

The inventive method is simple to use and allows you to quickly carry out dynamic control of interstitial pressure in a difficult general condition of the patient.

Using the proposed method is illustrated by the following examples.

Example 1

Patient Ch-ko V.A., 31, medical history No. 14501, was admitted to the orthopedic and traumatology department of the Regional Clinical Hospital No. 1 of Rostov-on-Don on September 6, 01, with complaints of pain in the left forearm and impaired function . According to the patient, he was injured on September 5, 01, when falling from a height of about 2 meters with an emphasis on his left hand. When viewed in the admission department: the left forearm and a pale pale brush, pronounced intense swelling of the soft tissues in the lower third of the left forearm, deformation, pathological mobility are determined. Ripple on the radial artery is reduced. Hyposthesia on the palmar surface of the left hand is determined. Active movements in the fingers are sharply limited.

On the radiograph of the left forearm, a fracture of both bones of the forearm in the lower third with an offset is determined.

On the basis of the clinical and radiological picture, the diagnosis was made: a closed fracture of both bones of the left forearm with a displacement, a severe closed injury of the soft tissues of the left forearm, acute tissue hypertension syndrome.

The patient was sent to the intensive care unit, where infusion therapy was started, periarterial blockade was made with 1% novocaine solution. A general clinical examination and diagnosis of tissue hypertension syndrome was performed using the Gradient-4 apparatus. The interstitial pressure of the left forearm was 30% higher than the pressure in the muscles of the right forearm.

In an emergency, a fasciotomy was performed under the conduction anesthesia in the projection of the internal radial fascial site. Distraction sutures were applied to the wound, osteosynthesis of a fracture of the forearm bones was performed using the Ilizarov apparatus. The postoperative period was uneventful, as the swelling subsided on the 3rd day after the operation, the edges of the skin wound were brought together by distraction sutures, the wound healed by first intention. Skin sutures were removed on day 12. The patient was discharged for outpatient treatment on the 19th day. In the distant period, consolidation of the fracture was observed after 3 months, full function in adjacent joints, the absence of edema and pain in the left forearm. The Ilizarov apparatus was dismantled, rehabilitation measures (physiotherapy, exercise therapy) were continued. During the control examination after 4 months from the moment of injury, a complete restoration of the function of the left upper limb was noted. On the electromyogram of the muscles of the forearm (Fig. 1, left - rest, right - stress, 1 - before surgery; 2 - 30 days after surgery; 3 - 6 months after surgery; 4 - one year after surgery) there are no trigger zones.

Example 2

Patient M-ko A.S., 20 years old, medical history No. 2016, was admitted to the orthopedic and traumatology department of the Regional Clinical Hospital No. 1 of Rostov-on-Don on 12/11/96 with a diagnosis of Closed diaphyseal fracture of both bones of the right forearm of the middle third with offset.

He was injured on 12/07/96, in domestic conditions. He was treated before admission to the place of residence in the Morozov Central District Hospital: an attempt at closed reposition, a circular plaster cast to the upper third of the right shoulder.

At the time of admission, deformity and swelling at the fracture site are noted. On palpation, sharp pain and crepitus of bone fragments are noted.

A general clinical examination and diagnosis of tissue hypertension syndrome was performed using the Gradient-4 apparatus. It was established that the interstitial pressure of the right forearm is 43% higher than the pressure in the muscles of the left forearm.

An X-ray examination determines the fracture of both bones of the forearm with an angular displacement.

An urgent Henry fasciotomy was performed, and transosseous compression osteosynthesis according to Ilizarov was performed. In the postoperative period, one remounting of the compression-distraction apparatus was required. The arrangement of the apparatus consisted of three rings, in each ring two mutually intersecting spokes were made.

When the patient re-contacted on March 20, 1997, an X-ray examination was performed, which revealed a slowdown in the consolidation of the fracture, clinically and radiologically it occurred after 5 months. After dismantling the apparatus, additional gypsum immobilization was required.

When examining the patient 6 months after the operation, swelling of the soft tissues in the area of damage is revealed. Palpation is determined by pain on the back of the forearm. EMG of the muscles of the forearm shows high-frequency electric potentials, uneven in amplitude. The voltage of the oscillations at rest is 75.00 ± 1.24 μV and at a voltage of 100.00 ± 4.16 μV. The mode of muscle work is isotonic. On the electromyogram of the muscles of the forearm (figure 2, left - rest, right - tension, 1 - before surgery; 2 - 30 days after surgery; 3 - 6 months after surgery; 4 - one year after surgery) muscles contract in an isometric mode. A repeated examination with the Gradient 4 apparatus found that the interstitial pressure of the muscles of the right forearm is 15% higher than the interstitial pressure of the muscles of the left forearm. The patient developed pain myofascial syndrome of the muscles of the forearm.

List of references

1. “Herald”, 1996, No. 4, pp. 2-5.

2. Human Physiology, Mir, Moscow, 1996, Volume 2, edited by R.F.Schmidt and G. Thews, pp. 498-506.

3. Liev A.A., Manual therapy of myofascial pain syndromes., "Dneprkniga", Dnepropetrovsk, 1993.

4. RF patent No. 2181983 dated 05/10/2002.

Claims (1)

A method for the diagnosis of acute tissue hypertension syndrome in injuries of the forearm bones by non-invasive registration of interstitial pressure, characterized in that synchronous recording of interstitial pressure of the muscles of the affected forearm and healthy is performed, the percentage of the difference in these values is calculated and the complicated course of the closed fracture of the forearm with acute tissue hypertension syndrome is predicted with increasing 30% or more.

Images