RU2823732C1 - Method of treating transcondylar extensor fractures of humerus with displacement not eliminated after reposition, presence of significant oedema and epidermal blisters - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to traumatology and orthopaedics, and can be used for treating transcondylar extensor fractures of humerus with displacement not eliminated after reposition, presence of oedema and epidermal blisters. Method involves anaesthesia, insertion of a K-wire through an olecranon and its fixation in a semi-ring support, installation of a system of blocks for performing longitudinal and lateral traction with elimination of displacement. Skeletal traction is performed under general anaesthesia; epidermal blisters are opened with application of aseptic dressings. Rotational displacement is eliminated by placing the shoulder in the abduction position with elbow flexion at angle of 90°, and the forearm is placed between pronation and supination so that the first finger of the hand of the injured segment is located opposite the bridge of the nose, for 4-5 days. X-ray inspection is used to determine elimination of rotational displacement, displacement in length and width. Without removing the limb from the skeletal traction, performing the transosseous cruciform fixation of the fracture with two K-wires, which pass through the lower portions of the internal and external epicondyles of the humerus at angle of 45° to the longitudinal axis of the shoulder, intact to the ulnar fossa. X-ray control is performed. Extremity is removed from the traction; the wire delivered through the olecranon is removed. Plaster splint is applied from the heads of the metacarpals to the upper one-third of the shoulder.

EFFECT: method provides reduction of traumatism of treatment, improvement of patient’s quality of life during fracture consolidation with reduction of length of stay in hospital, with better functional outcome and possibility of early rehabilitation due to transosseous cruciform fixation of fracture intact in ulnar fossa without removal of extremity from skeletal traction.

1 cl, 5 dwg, 1 ex

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used in the treatment of supracondylar fractures of the humerus in children after repeated unsuccessful repositions, and in the presence of significant soft tissue edema and multiple epidermal blisters.

Supracondylar fractures of the humerus are among the most common injuries of the musculoskeletal system in children, especially preschoolers, and account for about 12% of all types of fractures. Treatment of fractures of this localization in pediatric traumatology is quite difficult for a number of reasons.

1. In case of supracondylar fractures of the humerus, it is necessary to know that the insidiousness of this type of injury lies in the obligatory presence of three types of displacement: lengthwise, widthwise, and, perhaps, the most severe type of displacement - rotational. It should be noted that the less invasive the reposition is, the better the functional result. In this regard, the elbow joint is one of the most "capricious" ones.

2. Supracondylar fractures are intra-articular, and the presence of the above-mentioned displacements requires precise repositioning, with restoration of the anatomical and axial relationships of the bone fragments, which ensures sufficient range of motion in the elbow joint and its correct shape.

More common are supracondylar fractures, which are intra-articular, with damage to the above-mentioned structures, which requires precise repositioning, without which it is impossible to restore both a sufficient range of motion in the elbow joint and its correct shape.

3. Rapid development of post-traumatic edema and blood imbibition of the damaged area complicates the already difficult and skill-demanding closed reposition, which is often complicated by the intervention of specialists with insufficient experience in pediatric traumatology. As a result, when repositioning has been performed repeatedly and by different specialists, in addition to skin complications in the form of extensive epidermal blisters and multiple wounds, it becomes impossible to establish the direction of fragment rotation radiologically.

5. Frequent (about 50%) instability of these injuries is caused by the pronounced obliqueness of the fracture plane, sometimes by the comminuted nature of the injury, accompanied by a rupture of the shoulder muscle, joint capsule, which causes instability of fragments and a large number of secondary displacements during conservative treatment.

A major problem is the treatment of supracondylar humeral fractures after repeated unsuccessful attempts at closed reposition, especially if the reposition was performed by traumatologists who do not have the experience of reducing this type of fracture (for example, traumatologists providing care to adults). First of all, this is due to the inability to completely eliminate the rotational displacement, even in cases where the traumatologists have satisfactorily eliminated the length and width of the fragments. All patients admitted to our inpatient treatment had unresolved rotational displacement during the primary reposition performed at the place of residence. Repeated attempts at one-stage closed manual reposition are sometimes performed up to 5 times, leading iatrogenically to the fracture of the ends of the bone fragments, which become interponates, which complicates the high-quality performance of reposition.

Patients admitted with transcondylar fractures, who have undergone multiple unsuccessful repositions due to significant edema and the presence of numerous epidermal blisters, are unable not only to palpate bone fragments, but also to select a site on the skin for inserting pins after the planned reposition. Consequently, the pediatric traumatologist, when treating such patients, in addition to matching the fracture fragments with subsequent fixation, has the primary task of treating significant soft tissue edema with numerous epidermal blisters.

A method of surgical treatment of supracondylar fracture of the humerus with displacement in children and adolescents is known, in which, after open reposition of the humerus fracture, the fragments are fixed with Kirschner wires or injection needles [Traumatology of Childhood G.A. Bairova, Leningrad. 1976 p.204-205]. The method is carried out as follows. A layer-by-layer incision is started from the apex of the olecranon, it is carried out from behind, along the midline of the shoulder upwards by 6-7 cm. After dissecting the proper fascia, the tendon stretch and fibers of the triceps muscle are stratified in the longitudinal direction along the length of the incision. It is not necessary to dissect the periosteum, since it is usually damaged and exfoliated from the bone, as is the joint capsule. Blood clots are removed from the joint cavity. For easier access to the fracture site, the wound is widened by a T-shaped dissection of the triceps tendon above the olecranon process in both directions by 0.5-1 cm. Then, reposition and fixation of the fragments are started by “pinning” with Kirschner wires or injection needles. Under visual control, single-pronged sharp hooks are used to precisely align the fragments; the achieved position is held by an assistant. Then, two Kirschner wires are taken, the skin is pierced with them one by one at the level of the epicondyles, and passed through the distal fragment. The parts of the wires that rise above the skin are covered with napkins. On the operating table, it is necessary to ensure that the fixation is strong enough, for which, under visual control, several flexion and extension movements are performed in the elbow joint. The surgical wound is sutured layer by layer with catgut, and thin nylon sutures are applied to the skin. External fixation is performed with a plaster splint.

The disadvantage of this method of treatment is a significant incision of the skin, paraosseous and paraarticular tissues, as well as their skeletonization, which can lead to aseptic complications, such as delayed consolidation of the fracture and aseptic necrosis of the distal fragment of the humerus. In addition, this method is not applicable to patients with a transcondylar fracture, with significant edema and multiple epidermal blisters.

The closest, in its technical solution, is the method of positional treatment, using skeletal traction, giving the shoulder a vertical position. We have adopted it as a prototype. The technique of skeletal traction is relatively simple and does not require special equipment. The operation is performed under local anesthesia. A Kirschner wire is passed through the olecranon, and a horseshoe is fixed. TSITOV [Children's Traumatology G.A. Bairova, Leningrad. 1976, p. 202-203]. A system of blocks is used to perform longitudinal and lateral traction, gradually eliminating the displacement. The position of the fragments is controlled radiologically. The traction period ranges from 17 to 24 days. In case of posterior displacement of the fragment, traction is performed with the limb raised and bent at the elbow joint. If there is anterior displacement, traction is performed in an extended position of the limb, with additional downward traction for the displaced fragment (at the same time, countertraction is created). On the 8th-9th day, the forearm is carefully bent to a right angle, and traction is continued for another 10 days.

However, the intolerance of a small patient to a forced position in bed, the duration of bed rest, on average 21-24 days, the child's anxiety, the complexity of caring for the patient, etc., limit the use of the skeletal traction method in children, especially younger ones.

The purpose of the proposed invention is to develop a method for treating transcondylar fractures with unresolved displacement and the presence of significant edema and epidermal blisters, which provides for the elimination of all types of displacement, allowing the patient to avoid repeated operations.

The essence of the invention consists in a set of essential features sufficient to achieve the desired technical result, consisting in the possibility of performing reposition and stable osteosynthesis of a transcondylar fracture of the humerus in children with edema and multiple epidermal blisters with a decrease in the trauma of treatment, an improvement in the "quality of life" of the patient during fracture consolidation, with a reduction in the length of hospital stay, with a better functional outcome and the possibility of early rehabilitation.

The essence of treatment of supracondylar extension fractures of the humerus with displacement not eliminated after reposition, the presence of edema and epidermal blisters includes anesthesia, insertion of a Kirschner wire through the olecranon process and its fixation in a semicircular support, installation of a block system for longitudinal and lateral traction, with the elimination of displacement. Skeletal traction is performed under general anesthesia, epidermal blisters are opened, with the application of aseptic dressings. Rotational displacement is eliminated by placing the shoulder in the abduction position with flexion of the limb at the elbow joint at an angle of 90 °, and the forearm in a position between pronation and supination so that the first finger of the hand of the damaged segment is opposite the bridge of the nose for 4-5 days. X-ray control is performed to determine the elimination of rotational displacement, displacement along the length and width. Without removing the limb from skeletal traction, transosseous cruciate fixation of the fracture is performed with two Kirschner wires, which are passed through the lower sections of the internal and external epicondyles of the humerus, at an angle of 45 (to the longitudinal axis of the shoulder, intact to the olecranon fossa. X-ray control is performed. The limb is removed from traction, the wire passed through the olecranon is removed, and a plaster splint is applied to the limb from the heads of the metacarpal bones to the upper third of the shoulder.

The implementation of skeletal traction of the injured limb using the Balkan frame and block system under general anesthesia is due to the fact that the procedure is quite long and traumatic: during the installation of traction, the fragments are repeatedly moved, causing pain. In addition, according to the order of M3, all invasive manipulations in children must be performed under general anesthesia.

Epidermal blisters are gently opened with the tip of a scalpel to evacuate the contents and relieve increasing pressure due to the constant accumulation of serous fluid under the epidermis, increasing detachment of the epidermis of the skin from the underlying tissues. The application of aseptic pressure dressings ensures the closure of the walls of the epidermal cavity with the underlying tissues.

Failure to eliminate rotational displacement in this type of fracture leads to the formation of secondary deformation in the form of valgus deformity of the elbow joint. Placing the forearm in a middle position between pronation and supination so that the first finger of the hand of the damaged segment is at the level of the patient's head, with orientation to the bridge of the nose, using the Balkan frame and a system of blocks, allows for the reposition of fragments in 4-5 days. During this period, the epidermal blisters in the area of the condyles close, which makes it possible to insert Kirschner wires.

X-ray control ensures the quality of reposition is checked.

Transosseous cruciate fixation of the fracture with two Kirschner wires, which are inserted at low drill speeds through the lower sections of the internal and external epicondyles of the humerus, at an angle of 45° to the longitudinal axis of the shoulder, intact to the olecranon fossa, without removing the limb from skeletal traction, ensures the preservation of the achieved reposition. The angle of insertion of the wires, equal to 45°, allows bypassing the olecranon and coronoid fossa, since the presence of bone chips formed during drilling even with a wire in these fossa leads to the formation of osteophytes and joint contracture.

Performing skeletal traction, inserting a Kirschner wire through the olecranon, and fixing it in a semicircular support ensures the elimination of all types of fragment displacement, and the possibility of fixing the fracture with two Kirschner wires, after which skeletal traction is removed and the wire is removed.

A plaster splint applied from the heads of the metacarpal bones to the upper third of the shoulder allows the fragments to be held in a resurfaced position and creates optimal conditions for wound healing.

Failure to eliminate rotational displacement in this type of fracture leads to the formation of secondary deformation in the form of valgus deformity of the elbow joint. Exposing the forearm under skeletal traction, in a position of external rotation, so that the first finger of the hand of the damaged segment is at the level of the patient's head, with orientation to the bridge of the nose, using the Balkan frame and a system of blocks, ensures its elimination in 4-5 days. This position of the forearm between supination and pronation creates optimal conditions for balancing the antagonist muscles of the elbow joint area, and conditions for the positional position of the distal fragment to eliminate rotational displacement.

The illustrations show radiographs for a clinical example of patient I-va, 6 years old, where:

Fig. 1. - X-ray upon admission;

In Fig. 2 - on the 3rd day of skeletal traction;

Fig. 3 is a direct projection image after repositioning and fixation with pins;

In Fig. 4 - on the 4th day of skeletal traction, before fixation of the fracture with pins;

Fig. 5 is a lateral projection image after repositioning and pin fixation.

The method is carried out as follows.

Skeletal traction is performed under general anesthesia. The Kirschner wire is passed through the olecranon and, fixing it in a semicircular support, a block system is installed. Using the Balkan frame and the block system, longitudinal and lateral traction is performed, eliminating displacement. Epidermal blisters are opened, with the application of aseptic pressure bandages. The shoulder is placed in the abduction position with flexion of the limb at the elbow joint at an angle of 90°. The forearm is placed in a middle position between pronation and supination so that the first finger of the hand of the damaged segment is opposite the bridge of the nose for 4-5 days. X-ray control is performed to determine the elimination of rotational displacement, displacement along the length and width. Without removing the limb from skeletal traction, transosseous cruciate fixation of the fracture is performed with two Kirschner wires, which are passed through the lower sections of the internal and external epicondyles of the humerus, at an angle of 45 (to the longitudinal axis of the shoulder, intact to the olecranon fossa. The ends of the wires are bent over the skin and aseptic dressings are applied, fixing them with several turns of bandage. X-ray control is performed, the limb is removed from traction, the wire passed through the olecranon is removed. A plaster splint is applied to the limb from the heads of the metacarpal bones to the upper third of the shoulder.

Clinical example.

Patient I-V, 6 years old, fell in the street on an almost fully extended arm, admitted to hospital on 23.05.22. After clinical and radiographic examination (Fig. 1), the diagnosis was: supracondylar extension fracture of the left humerus with displacement of fragments. An attempt at reposition was made at the Central Regional Hospital at the place of residence. Unsuccessful. The limb was splinted with transport immobilization. Upon admission to the Republican Clinical Hospital: after removing the transport immobilization, significant edema and the presence of numerous epidermal blisters in the area of the internal and external epicondyles of the humerus are determined. Skeletal traction was performed under general anesthesia. A Kirschner wire was passed through the olecranon and fixed in a semicircular support - a CITO horseshoe, a block system was installed. Using the Balkan frame and the block system, longitudinal and lateral traction was performed, the displacement was eliminated. Large epidermal blisters were gently opened and aseptic pressure dressings were applied. The patient was examined and bandaged the following day: the swelling had decreased. On the 3rd day, the swelling was stopped, and epithelialization was observed at the sites of blisters opening. The X-ray control image (Fig. 2), taken in the lateral projection, showed the elimination of rotational displacement and displacement along the length, and palpation revealed the elimination of displacement along the width. The following day, after repeated X-ray (Fig. 3), cruciate fixation of the fracture was performed with two Kirschner wires: the shoulder was put in the abduction position with flexion of the limb at the elbow joint at an angle of 90°. The forearm was placed in the middle position between pronation and supination so that the first finger of the hand of the damaged segment was opposite the bridge of the nose. After the pins were inserted, an X-ray was taken (Fig. 4), the limb was removed from traction, and the pin inserted through the olecranon was removed. A plaster cast was applied from the heads of the metacarpal bones to the upper third of the shoulder. The patient was discharged for outpatient treatment the following day. Thus, the patient's inpatient treatment lasted 5 bed-days.

Claims (1)

A method for treating transcondylar extension fractures of the humerus with displacement not eliminated after reposition, the presence of edema and epidermal blisters, including anesthesia, insertion of a Kirschner wire through the olecranon and its fixation in a semicircular support, installation of a block system for performing longitudinal and lateral traction with the elimination of displacement, characterized in that skeletal traction is performed under general anesthesia, epidermal blisters are opened with the application of aseptic dressings, rotational displacement is eliminated by placing the shoulder in an abduction position with flexion of the limb at the elbow joint at an angle of 90 °, and the forearm in a position between pronation and supination so that the first finger of the hand of the damaged segment is opposite the bridge of the nose, for 4-5 days, by conducting X-ray control, the elimination of rotational displacement, displacement along the length and width is determined without removing the limb from skeletal traction, transosseous cruciate fixation of the fracture with two Kirschner wires, which are inserted through the lower sections of the internal and external epicondyles of the humerus at an angle of 45° to the longitudinal axis of the shoulder, intact to the olecranon fossa, X-ray control is performed, the limb is removed from traction, the wire inserted through the olecranon process is removed, a plaster splint is applied to the limb from the heads of the metacarpal bones to the upper third of the shoulder.