RU2798960C1 - Method of surgical treatment of adduction contracture of the first finger combined with instability of the metacarpophalangeal joint, in a patient with cerebral palsy - Google Patents

Abstract

FIELD: medicine; traumatology; orthopedics.

SUBSTANCE: invention can be used for surgical treatment of adduction contracture of the first finger combined with metacarpophalangeal joint (MPJ) instability, in a patient with cerebral palsy. The method includes performing Z-shaped plasty of the first interdigital space, transection of the muscles adducting the first finger until 80 degrees of finger abduction is reached, temporary fixation of the metacarpophalangeal joint with a bone plate with angular stability and screws in the joint flexion position of 10 degrees for 1 year. During fixation, three screws are inserted into the metacarpal bone, two screws are inserted into the main phalanx, all screws are inserted in such a way that they pass through both cortical layers.

EFFECT: method ensures elimination of the adductor contracture of the first finger of the hand due to the preservation of the PPS.

1 cl, 6 dwg

Description

SUBSTANCE: invention relates to medicine, in particular to orthopedics, and can be used for surgical treatment of adduction contracture of the first finger, combined with instability of the metacarpophalangeal joint, in a patient with cerebral palsy.

As part of the “spastic hand” syndrome, adductor or flexion-adductor contracture of the first finger of the hand (“trumb-in-palm deformity”) is less common than others, but often it is it that limits the function of the hand [Alewijnse J.V., Smeulders M.J., Kreulen M. Short-term and long-term clinical results of the surgical correction of thumb-in-palm deformity in patients with cerebral palsy. J. Pediatric Orthop. 2015.vol. 35 no. 8. P. 825-830]. The function of the brush is to capture and move objects. The possibility of this is provided mainly due to the mobile, opposed to all the rest of the first finger. The brush and fingers cover the entire object at once or capture it with the tips of the 1st and other fingers [Kapanji A.I. Upper limb. Physiology of the joints. Volume 1. Publisher. Eksmo, 2009. 6th edition. pp. 201-204. S. 255].

Adductor contracture of the first finger of the hand limits the process: self-service, dressing, eating, learning, as well as playing and other areas of activity.

Weakening of the muscles that extensor and abduct the first finger (m.abductor pollicis longus, m.extensor pollicis longus et brevis), against the background of high tone or shortening of the muscles that flex and adduct the finger (m.flexor pollicis longus et brevis, m.adductor pollicis) , are the cause of the formation of trumb-in-palm deformity in patients with cerebral palsy.

Flexion-adductor contracture of the first finger, according to J.H. House [House J.H, Gwathmey F., Fidler M. A dynamic approach to the thumb-in-palm deformity in cerebral palsy. J Bone Joint Surg. 1981.vol. 63. P. 216-225], ultimately leading to disruption of relationships in the carpometacarpal, metacarpophalangeal and interphalangeal joints. Instability, due to dislocation in the metacarpophalangeal joint (MPJ), is most common, while the direct cause of its formation is the restriction of abduction and extension of the first metacarpal bone. PFS instability mainly occurs against the background of a combination of contracture of the intermetacarpal muscles and a short flexor of the finger, provided that sufficient strength of the extensor muscles of the finger is maintained. Under conditions of adduction contracture of the first finger, dislocation in the PFS becomes a necessary element of abduction and extension of the first finger, while sharply violating the biomechanics of the hand.

In the process of formation of the adductor contracture of the first finger, a secondary skin deficiency is gradually formed in the area of the first interdigital space.

At the initial stages of contracture formation, conservative methods of treatment are used, which include: orthotics, medical and physical treatment, as well as injections of botulinum toxin. If conservative methods are not sufficient to correct trumb-in-palm deformity, surgical treatment should be considered.

Known methods of surgical treatment of flexion-adductor contracture of the first finger in combination with hyperextension in the PFS can be conditionally divided into two types: soft tissue and arthrodesis [Tranchida G.V., Van Heest A.E. Outcomes After Surgical Treatment of Spastic Upper Extremity Conditions. Hand clinics. 2018.vol. 34 no. 4. P. 583-591]. The first type includes surgical interventions aimed at passive and active increase in the amplitude of extension and abduction of the first finger. This is achieved due to the release of the first interdigital space in combination with skin plasty of this area, followed by muscle transposition [Tranchida G.V, Van Heest A.E. Preferred options and evidence for upper limb surgery for spasticity in cerebral palsy, stroke, and brain injury. The Journal of hand surgery, European. 2020.vol. 45 no. 1. P. 34-42]. The second group of operations includes the creation of a functionally beneficial arthrodesis of the first metacarpophalangeal joint [Wood K.S., Daluiski A. Management of Joint Contractures in the Spastic Upper Extremity. Hand Clinics. 2018.vol. 34 no. 4. P. 517-528]. In addition to the obvious positive results of existing surgical techniques, there are also quite significant negative points [Petuchowksi J., Kieras K., Stein K. Rehabilitation Strategies Following Surgical Treatment of Upper Extremity Spasticity. Hand Clinics. 2018.vol. 34 no. 4. P. 567-582].

The first group of operations is logically subject to a high recurrence rate, is very dependent on rehabilitation measures, and is extremely limited by the patient's motivation. The negative aspects of the second group of operations include: prolonged postoperative immobilization, the risk of forming a false joint, the irreversibility of arthrodesis. Lack of movement in the PFS permanently changes the biomechanics of the grip of the hand, which can create some inconvenience for the patient.

In his study Alewijnse [Alewijnse J.V., Smeulders M.J., Kreulen M. Short-term and long-term clinical results of the surgical correction of thumb-in-palm deformity in patients with cerebral palsy. J. Pediatr Orthop. 2015. vol. 35 no. 8. P. 825-830] described a five-year follow-up of a group of patients in whom he and his colleagues eliminated the adductor contracture of the first finger according to the standard technique, performed rerouting of the T. extensor pollicis longus tendon, and also stabilized the PFS due to its capsulodesis. After 1 year, 13% of patients developed a recurrence of the deformity, and after 5 years, a recurrence was observed already in 29% of children. Thus, it is obvious that it is PFS instability that negatively affects the outcome of surgical treatment. An alternative to capsulodesis is PFS arthrodesis with all the obvious disadvantages described above. Therefore, we were faced with the task of stabilizing the PFS without its final closure, but with more stable results than with capsuloplasty.

We proceeded from the assumption that prolonged immobilization of the joint in a functionally advantageous position, not accompanied by intervention on its elements, may ultimately lead to retraction of the ligamentous-capsular apparatus. Against the background of changes that have occurred in a long-term immobilized joint, after removal of the fixing structure, the amplitude of movements should decrease, primarily due to the pathological extensor sector. At the same time, the possibility of early rehabilitation in the absence of contracture and stable PFS should contribute to the formation of the balance of the muscles of the first finger, which is also a prevention of the development of contracture recurrence.

The objective of the proposed method is to combine both types of surgical interventions aimed at eliminating the adductor contracture of the first finger in unstable PFS, while taking into account the shortcomings of existing techniques.

The technical result of the task is achieved as follows: from a Z-shaped incision 5 cm long in the first interdigital space with the formation of two figures of triangular flaps (Fig. 1) is isolated and mobilized from the surrounding tissues m. adductor pollicis, m.flexor pollicis brevis, m.interosseus dorsalis. The abduction-limiting muscles are transversely crossed at their insertion on the first metacarpal bone until a final abduction of the thumb of 80° is achieved. (Fig. 2.).

Temporary arthrodesis of the PFS with a bone plate is performed from the same surgical access. After subperiosteal exposure of the proximal phalanx of the first finger and metacarpal bone, the PPS is fixed with a plate with angular stability in a neutral physiological position of 10° flexion. 3 screws are inserted into the metacarpal bone, 2 screws into the main phalanx. All screws are inserted in such a way that they pass through both cortical layers (Fig. 1b). After arthrodesis of the PFS, x-ray control is carried out (Fig.). When suturing the surgical wound, triangular skin flaps are moved in such a way as to eliminate the desmogenic component of the contracture. Immobilization with a plaster splint in the position of abduction and opposition of the first finger is carried out for 2 weeks, until the sutures are removed after complete healing of the surgical wound. After removing the sutures, a complex of rehabilitation and recovery measures begins. The metal structure stabilizing PFS is removed after 1 year (Fig.).

The figures show the stages of the method of surgical treatment of adductor contracture of the first finger, combined with instability of the metacarpophalangeal joint, in a patient with cerebral palsy.

Fig. 1 - surgical access with Z-shaped plastic

Fig. 2 - released the first interdigital space

Fig. 3 - temporary arthrodesis of the PFS was performed with a bone plate

Fig. 4 - radiograph of the hand before and after surgical treatment.

Before surgical treatment, the patient has a dislocation in the PFL; after surgical treatment, the PFL was temporarily arthrodized with a bone plate and screws.

The positive effect of the proposed method lies in the combination of the classical soft tissue technique for eliminating the adductor contracture of the first finger with temporary arthrodesis of the PFS. This combination reduces the time of immobilization (they are limited by the healing of the edges of the surgical wound after Z-shaped plasty and is usually 2-3 weeks) and completely eliminates the possibility of early recurrence of dislocations in the PFS. The removal of the metal structure of the arthrodesis PFS, performed a year after surgical treatment, returns physiological movements, which allows preserving this joint as a biomechanical segment of the hand. The results of surgical treatment according to the proposed method are shown in Fig. 5 and 6.

Fig. 5 - condition of the hand before surgical treatment.

Fig. 6 - the state of the patient's hand 3 years after the removal of the metal structure of the arthrodesis PFS.

Claims (1)

A method for surgical treatment of adductor contracture of the first finger, combined with instability of the metacarpophalangeal joint, in a patient with cerebral palsy, which includes performing a Z-shaped plasty of the first interdigital space, crossing the muscles adducting the first finger until finger abduction reaches 80 degrees, temporary fixation of the metacarpophalangeal joint with a bone plate with angular stability and screws in the position of flexion in the joint of 10 degrees for 1 year, moreover, during fixation, three screws are inserted into the metacarpal bone, two screws are inserted into the main phalanx, all screws are inserted in such a way that they pass through both cortical layers.

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