RU2371134C1 - Surgery technique for forearm dislocations - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to orthopaedics and traumatology, and can be used in surgery technique for forearm dislocations. Posterior approach is provided by linear longitudinal dissection throughout 18-20 cm in a posterior projection of elbow joint, triceps - between CLB and medial head, to periosteum. Then periosteum is dissected on lateral edge of ulnar bone which is prepared in the top one-third with olecranon. Deep flexor muscle of fingers, ulnar flexor muscle of wrist and anconeus muscle are cut off from the bone. A capsule is dissected crosswise, and with using a lever tool olecranon is moved to ensure normal anatomical proportion with articular surface of humeral bone. Periosteum is sutured. Cut off parts of deep flexor muscle of fingers, ulnar flexor muscle of wrist and anconeus muscle are fixed to the anatomic attachment, transolecronally with spokes of joint angle 90-110 degrees.

EFFECT: method allows providing complete recovery of active status of full restoration of superior limb, sparing approach to elbow joint, eliminating or reducing postoperative complications, reducing time of medical and social rehabilitation of the patient.

1 ex, 5 dwg

Description

 The present invention relates to medicine, namely to cortopedia and traumatology, and can be used in the surgical treatment of dislocations and fracture-dislocations of the forearm, including chronic ones.

Known methods of treating this pathology include cutting off the apex of the ulnar process along with the triceps muscle tendon attached to it, the ulnar nerve is secreted, the ulnar muscle is separated from the external condyle of the shoulder, a tongue-like flap is cut out of the aponeurosis of the triceps muscle, with the base on the ulnar process and the tendon muscle including , which is accompanied by extensive trauma to the soft tissues, which during treatment leads to the development of complications: suppuration, damage to blood vessels, nerves, lengthening the term rehabilitation resistant contracture of the elbow joint, ankylosis. The following types of forearm dislocations are distinguished: dorsal, ventral, ulnar, radial, isolated ulnar dislocation, isolated radial dislocation. An urgent problem of modern traumatology - orthopedics - is the further development of effective surgical methods for treating forearm dislocations and fractures. This pathology is more common in people of working age and the elderly. Unadjusted dislocations of the forearm, fractured dislocations of the forearm with displacement, including chronic ones, are an absolute indication for surgical treatment, since a good functional result is needed. Patients are concerned about pain and impaired function of the elbow joint, limb, and, over time, these problems remain. Unoperated forearm dislocations, fractures of the forearm with displacement, including old ones, can lead to damage or compression of the vessels and nerves, as well as to later complications - ankylosis, severe atrophy of the shoulder girdle, accompanied by severe contractures, which can be treated very hard . These complications can be avoided using the earliest possible surgical treatment with open reduction of dislocations, and accurate reposition of bone fragments with reliable and non-traumatic internal osteosynthesis. When analyzing domestic and foreign literature on the surgical treatment of dislocations and fractures of the forearm, including old ones, it should be noted that one of the most common and effective methods of their treatment is open reduction of the dislocation, reposition of fractures with metal osteosynthesis. Among the described methods there is no clear indication for the use of each of them.

A known method of open reduction of dislocations of the forearm, described by I.A. Movshovich (Operational Orthopedics. "Medicine", Moscow, 1983, 415 pp., Pp. 99-105). In this case, the open reduction of the dislocation of the forearm is carried out by the rear operative access along Murphy-Lexer. The method of open reduction of the dislocation of the forearm is performed in the following order. The incision is from a point 2 cm above the external epicondyle of the shoulder, then arcuately down 5-6 cm below the ulnar process, and then up to the internal epicondyle slightly above it. After dissecting their own fascia on the forearm, carefully, along the probe, dissect the fascia in the interval between the ulnar process and the internal epicondyle. Here passes the ulnar nerve, which is easily palpated through the fascia. The nerve is secreted and taken on a rubber strip. Then, with the chisel, the apex of the ulnar process is knocked down and, together with the tendon of the triceps attached to it, is thrown up. Reduce the dislocation of the forearm, followed by fixing in place of the cut off fragment of the ulnar process with a screw. Manipulation is performed with x-ray control. The wound is closed by stitching. After surgery, immobilization is carried out with a plaster cast. The immobilization period is from 4 to 6 weeks. Subsequently, the development of contracture is prescribed. After this, rehabilitation is 8-10 weeks with the use of exercise therapy, massage, physiotherapy. The results of treatment are often unsatisfactory.

The disadvantages of the method of open reduction of the dislocation of the forearm, described by I.A. Movshovich using operational access Murphy-Lexer:

1) Frequent damage to anatomical structures: nerves, blood vessels, tendons.

2) The formation of contracture of the elbow joint.

3) Possible ankylosis of the joint.

4) Long rehabilitation periods (8-10 weeks).

5) Clipping of the ulnar process.

A method similar to Olier described by V. A. Sokolov Multiple and combined injuries (a practical guide for traumatologists, Moscow, publishing group “GEOTAR-Media” 2006, 510 pp., Pp. 112-419) was adopted as the closest analogue. . This is the most commonly used method that provides rear access with open reduction of forearm dislocations, in which a wide opening of the joint is performed. The method of open reduction of the dislocation of the forearm is performed in the following order. Make an incision with a bayonet-shaped shape. This incision is often combined with excision of the ulnar process. They begin it 6-8 cm above the apex of the ulnar process and lead distally, slightly bending around the ulnar process from the outside 6-8 cm below the apex of the ulnar process. The incision lead down somewhat lateral to the midline, then it passes through the projection of the radiolbow joint, sharply deviates to the medial side, crossing the base of the ulnar process, and then it is led down along the ulna. The length of the incision is 12-15 cm. With access to Olga, only one muscle is cut off - the ulnar muscle (m. Anconeus); it is separated from the external condyle of the shoulder. After that, the capsule of the joint opens. Dissect the capsule of the joint. Access provides sufficient joint opening. After that, a reduction in the dislocation of the forearm is performed. Perform reposition, metal osteosynthesis of the cut off elbow process. From this access it is possible to carry out interventions in the head and neck of the radius. The operation is completed by layering stitches on the wound. After surgery, impose a plaster cast. Immobilization in plaster from 4 to 6 weeks. Then carry out rehabilitation: exercise therapy, physiotherapy, massage for 4-5 weeks. The results of treatment are not always satisfactory.

The disadvantages of the method of open reduction of forearm dislocations described by V.A.Sokolov using online access Olie:

1) When performing the method, damage to nerves, blood vessels, and tendons is possible.

2) Possible contracture in the late postoperative period.

3) High trauma to soft tissues during the method.

4) A significant lengthening of the rehabilitation period.

5) Clipping of the ulnar process.

Tasks:

1. To reduce soft tissue trauma in the area of the elbow joint.

2. To prevent the development of infectious, postoperative complications.

3. Avoid iatrogenic damage to nerves and blood vessels.

4. To prevent the development of contracture of the elbow joint.

5. Prevent the development of ankylosis of the elbow joint.

The essence of the method is the preservation of tendons, muscles, blood vessels, nerves during surgical intervention, the implementation of gentle rear access to the working field by linear, longitudinal dissection for 18-20 cm in the rear projection of the elbow joint, triceps muscle between the long and medial head, to periosteum; then the periosteum is dissected along the lateral edge of the ulnar bone, the ulnar bone is prepared in the upper third with the ulnar process, the deep flexor of the fingers is cut off from the bone, the ulnar flexor of the hand and the ulnar muscle, the capsule is dissected crosswise and the ulnar process is moved crosswise to the normal anatomic ratio the articular surface of the humerus, and sutures on the periosteum, fix the cut off parts of the deep flexor of the fingers, the ulnar flexor of the hand and ulnar muscle to the place and anatomic attachment performed percutaneously, transolekronalno osteosynthesis needles with an angle of 90-110 degrees in the joint.

The technical result of the proposal is:

1) Ensuring full restoration of the working state of the upper limb.

2) Creating sparing access to the elbow joint.

3) Elimination or reduction of postoperative complications.

4) Reducing the time of medical and social rehabilitation of the patient by 40-50%.

The method was tested on 36 patients for 12 years.

Almost all operated patients were observed in subsequent

six months after the operation. These observations allow us to conclude that the proposed method is highly efficient.

The method is as follows: see Fig.1-2, where 1 - online access; 2 - medial head of the triceps muscle; 3 - the long head of the triceps muscle; 4 - humerus; 5 - ulnar nerve; 6 - ulnar process; 7 - deep finger flexor; 8 - ulnar bone; 9 - ulnar flexor of the brush; 10 - ulnar muscle; 11 - sutures on the periosteum of the ulna; 12 - osteosynthesis with needles.

Surgical access is performed under general anesthesia. Rear access to the elbow joint is carried out in the lower third of the shoulder, the upper third of the forearm to the elbow joint, in the position of the patient lying on his back, with his arm rotated inside and bent at the elbow joint to 130 degrees and laid on the chest. Depending on the size of the elbow joint, the size of the access is on average up to 18-20 cm (figure 1). Access 1 begins from the upper third - the middle third of the shoulder and ends at the level of the upper third - the middle third of the forearm. These access parameters make it possible to optimally distinguish all formations related to the elbow joint. Access is formed in the direction of the fibers of the (long) head of the triceps brachii 3 m. triceps brachii (caput longum) by dissecting layers of skin, subcutaneous tissue, shoulder aponeurosis (fascia brachii) and forearm aponeurosis (fascia antebrachii) below the lateral edge in the projection of the ulnar process 6 and the ulna go to the periosteum of the ulna. Access to the humerus 4 is provided by the separation of the medial side of the tendon and the muscle of the long head of the triceps brachii m. triceps brachii (caput longum) and the medial head of the triceps brachii 2 m. triceps brachii (caput mediale) along the entire length of the access to the articular fissure of the elbow joint and the place of muscle attachment to the condyles of the shoulder. Then, the upper third of the ulna bone 8 is prepared subperiostally with a raster, bypassing the ankle bone anteriorly from behind and from the sides, the deep flexor of the fingers 7 (m. Flexor digitorum profundus), the ulnar flexor of the hand 9 (m. Flexor carpi ulnaris) and the ulnar muscle 10 ( m. anconeus), retain on the front side of the attachment point of the superficial finger flexor m. flexor digitorum superficialis (caput ulnare), long flexor of the thumb m. flexor pollicis longus (caput ulnare), round pronator (m. pronator teres), brachial muscle (m.brachialis). This area of muscle attachment is limited on the lateral side by the comb of the muscle of the supination forearm (crista musculi supinatoris), on the medial side by the edge of the ulnar tuberosity (tuberositas ulnae). A safe reference point when working in the area of dislocation of the forearm are the bones - ulnar, radial, humerus. To achieve the reduction of the dislocation of the forearm, it is necessary to distinguish the bones of the joint subperiosteally, focusing on such anatomical structures as vessels, nerves passing nearby. Otherwise, it is difficult to accomplish. In the course of operative access, dissect, push apart, dissect tissues in the area of dislocation of the ulnar process, as well as the distal metaepiphysis of the shoulder, using a soft preparation clamp. They go into the zone of an existing dislocation of the forearm. The remains of the articular bag are dissected crosswise. At the same time, they are very careful not to damage the vessels and nerves passing nearby, especially the ulnar nerve 5, located behind the internal epicondyle. When the dislocation of the forearm is repaired, it can be traumatized. Using Buyalsky's spatula, incongruency in the elbow joint is eliminated, rotational movements under visual control achieve the reduction of dislocation in the elbow joint (figure 2). Sutures are placed on the periosteum 11, bringing together the cut off parts of the deep flexor of the fingers (m. Flexor digitorum profundus), the ulnar flexor of the hand (m. Fleksor carpi ulnaris) and the ulnar muscle (m. Anconeus), fix the place of anatomical attachment. Fixing with Kirschner knitting needles 12 percutaneously in the shoulder-elbow and radiolactic joints in order to avoid possible secondary dislocation with an angle in the joint of 90-110 degrees. Manipulation is carried out under R-control. Suture is applied in layers to the wound, leaving subcutaneous rubber graduates. Aseptic dressing. Plaster cast immobilization for two weeks. Then remove the plaster cast, remove the Kirschner spokes, and prescribe the development of contracture of the elbow joint with physiotherapy exercises until function is restored within 2-3 weeks. Limb function is restored almost completely.

For the period 1996-2008 36 patients were operated on in our clinic with dislocations of the forearm, of which 9 were women, 27 men. Of all the patients, 18 were operated on for a back dislocation of the forearm, 7 cases of a front dislocation, and also 11 cases of other dislocations fracture-dislocation. Postoperative complication - seroma occurred in 2 cases and was associated with somatic diseases preceding the injury. Almost all operated patients were followed up to six months after surgery. The treatment results are satisfactory.

In the majority of operated patients, restoration of the function of the elbow joint on average 2-3 weeks after removal of the plaster cast. Due to the low-traumatic, anatomical access in the early postoperative period and later in the area of operation, a predominantly minor pain syndrome was noted. Satisfactory treatment results were established for the operated patients; cases of incomplete restoration of function are not associated with surgical errors. (Failure to follow doctor's recommendations, patient negligence, etc.) Improvement was noted in all cases. The development of moderate contracture in 3 cases is associated with personality traits of patients. In no case were there such complications as ankylosis, damage to blood vessels and nerves.

The proposed surgical access for surgical treatment for chronic forearm dislocations reduces the likelihood of suppuration, damage to the ulnar, radial, median nerves, main vessels of the elbow joint area, as well as the main complication of dislocations, fractures of the forearm - ulnar joint contractures, with optimal treatment time and rehabilitation, reduce trauma to soft tissues, as well as traumatic preparation of soft tissues of the forearm, shoulder in the area of operation.

The advantages of the proposed method of surgical treatment with posterior operative access to dislocations, fractures, dislocations of the forearm, including chronic ones, are:

1) Reduces the risk of developing infectious complications in comparison with the use of operational access Olie, Murphy-Lexer.

2) Allows an anatomical way to achieve the elimination of dislocation of the forearm, to ensure complete cure.

3) Allows anatomical way to perform the reposition and osteosynthesis of fractures in the elbow joint.

4) It helps to prevent the development of contracture in the elbow joint.

5) Prevents the development of ankylosis in the elbow joint.

Along with this, the proposed method has some application limitations:

1) Age.

2) Diabetes mellitus in the stage of decompensation.

3) DEP of a severe degree.

Example. Patient L., 64 years old, and.b. No. 1173, was admitted to the clinic on April 25, 1999, six months after a household injury - she fell from a height to her right upper limb. After the injury, she did not go anywhere, was not treated.

Hospitalized for surgical treatment with a diagnosis of chronic elbow dislocation of the right forearm (photo No. 1). After a routine examination, 04/28/99. the patient underwent surgery: open reduction of the dislocation of the right forearm, resection of the radial head, percutaneous metal osteosynthesis with Kirschner spokes of the shoulder joint, drainage. The operation was performed under general anesthesia. Rear access to the elbow joint was performed in the lower third of the shoulder, the upper third of the forearm in the position of the patient lying on the back, with the arm rotated inwards and bent at the elbow joint to 120 degrees and laid on the chest. The access size is 20 cm. They started access from the upper third - the middle third of the shoulder and finished at the level of the upper third - the middle third of the forearm. Access was made in the direction of the fibers of the long head of the triceps brachii muscle triceps brachii (caput longum) by dissecting layers of skin, subcutaneous tissue, shoulder aponeurosis (fascia brachii) and forearm aponeurosis (fascia antebrachii) lower along the lateral edge in the projection of the ulnar process and ulnar bone left on the periosteum of the ulna. Access to the humerus was provided by disconnection from the medial side of the tendon and the muscle of the long head of the triceps brachii m. triceps brachii (caput longum) and the medial head of the triceps brachii m. triceps brachii (caput mediale) along the entire length of the access to the articular fissure of the elbow joint and the place of muscle attachment to the condyles of the shoulder. Then, the upper third of the ulna was dissected subcutaneously with a raster, bypassing the ankle bone anteriorly from behind and from the sides, a deep flexor of the fingers (T. flexor digitorum profundus), ulnar flexor of the hand (m. Fleksor carpi ulnaris) and ulnar muscle (m. Anconeus) were cut off. , saved on the inside - on the tuberosity of the ulnar bone of the attachment site of the superficial flexor of the fingers m. flexor digitorum superficialis (caput ulnare), long flexor of the thumb m. flexor pollicis longus (caput ulnare), round pronator (m. pronator teres), brachial muscle (m.brachialis). This area of muscle attachment is bounded on the lateral side by the scallop of the muscle supination of the forearm (crista musculi supinators), on the medial side by the edge of the ulnar tuberosity (tuberositas ulnae). A safe reference point when working in the area of dislocation of the forearm was determined by the bones - ulnar, radial, humerus. In the course of operative access, they dissected, parted, softened the scar tissue in the area of the dislocation of the ulnar process, as well as the distal metaepiphysis of the shoulder, using a soft preparation clamp. The remains of the joint bag were dissected crosswise. We went into the area of the existing dislocation of the forearm. At the same time, they were very careful not to damage the vessels and nerves passing nearby, especially the ulnar nerve, located behind the internal epicondyle. Using Buyalsky’s spatula, under visual control, incongruency was eliminated in the elbow joint, and with rotational movements, the dislocation in the elbow joint was repaired. In order not to extend the time of immobilization and, accordingly, rehabilitation, the radial head was resected from the same access. Fixation was performed in the shoulder-elbow joint percutaneously, transolecronally with two Kirschner spokes in order to avoid possible repeated dislocation of the forearm (photo No. 2). The manipulation was carried out under R-control. Sutures were made on the periosteum, the cut off parts of the deep flexor of the fingers (m. Flexor digitorum profundus), the ulnar flexor of the hand (m. Fleksor carpi ulnaris) and the ulnar muscle (m. Anconeus) were brought together, fixed to the site of anatomical attachment. Sutures on the wound were performed in layers, leaving subcutaneous rubber graduates. Aseptic dressing. Plaster cast immobilization for two weeks. Then they removed the plaster cast, and removed the Kirschner knitting needles. They appointed the development of contracture, physiotherapy exercises until function was restored within 4 weeks. The treatment result is satisfactory. Limb function restored almost completely. The patient was examined 9 years after surgical reduction of the dislocation of the forearm (photo No. 3). The function of the limb is preserved almost completely.

Claims (1)

A method of surgical treatment of dislocations of the forearm, including the formation of posterior access to the elbow joint, characterized in that with the condition that the tendons, muscles, vessels, nerves are preserved, posterior access is made by linear longitudinal dissection for 18-20 cm in the rear projection of the elbow joint, triceps muscle - between the long and medial head, to the periosteum, then cut the periosteum along the lateral edge of the ulnar bone, prepare the ulnar bone in the upper third with the ulnar process, cut off from the bone deep the flexor of the fingers, the ulnar flexor of the hand and the ulnar muscle, cross the capsule crosswise and use the lever tool to move the ulnar process to the normal anatomical relationship with the articular surface of the humerus and suture the periosteum, fix the cut off parts of the deep flexor of the fingers, ulnar flexor of the hand and ulnar muscle to the place of anatomical attachment, fix in the adjusted state the shoulder-elbow joint percutaneously, transorlekronno held needles with an angle in the joint 90-110 ° for two weeks.

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