RU2269319C1 - Method for surgical treatment of pronation contracture of forearm in case of juvenile cerebral palsy - Google Patents

Abstract

FIELD: medicine, orthopedics, traumatology.

SUBSTANCE: one should perform correcting osteotomy of the middle third of radius at simultaneously cutting a periosteal fragment that continue the tendon of round pronator in distal direction to separate it against cortical part of radius not dissecting it against the site of fixation to replace it through developed defect in radius from volar side onto its rear side by simultaneously lengthening the muscle's power action lever due to osteotomic level that decreases traumatism of operation, prevents possibility for damaging inter-osseous membrane, excludes the necessity in destructing the integrity of round pronator and dissecting it against the tendon and improves its subsequent function as a supinator due to increased power action lever.

EFFECT: higher efficiency of therapy.

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Description

The invention relates to the field of clinical medicine, namely orthopedics - traumatology, and can find application in the treatment of patients with cerebral palsy (cerebral palsy), with motor disorders of the upper extremities in the form of pronational contracture of the forearm.

Pronational forearm contracture is formed in children with spastic paralysis due to a pathological increase in the tone of the round pronator and square pronator and leads to a significant limitation of the function of the upper limb, especially if there is adducing contracture of the first finger and ulnar deviation of the hand.

The presence of pronational contracture of the forearm and hand is a disabling deformity in cerebral palsy even in the presence of a relatively favorable general neurological and orthopedic background, since it sharply limits the child's ability to self-care, use surrounding objects, study, etc.

A known method of surgical treatment of these deformities (Ovsyankin N.A., Malenkov N.N., Leonova S.F. Surgical methods for restoring the functions of the upper limb in cerebral spastic paralysis in children. Prevention, comprehensive treatment and medical and social rehabilitation of children with diseases supporting -motor apparatus. - Vladimir, 1988, - P. 44-46), in which arthrodesis of the wrist joints is performed with correction of pronational contracture of the forearm by 25-30 °.

In young children (3-7 years old), the operation was proposed to cut off the square pronator along with the periosteum from the radius, transverse dissection of the ligament of the articular disc of the distal radiolactic joint, correction of pronational contracture, metal osteosynthesis with two Kirschner spokes through the diaphysis of the radius and ulna in the position of achieved supination ( Malenkov N.N., Ovsyankin N.A. Treatment of pronational forearm contractures in children with spastic paralysis.Collection of abstracts of the inter-regional scientific-practical conference II. L., 1989, p.15-16, application for invention No. 4382856).

At the same time, Abalmasova E.A. considers arthrodesis surgery for spastic paralysis contraindicated (Pediatric Traumatology and Orthopedics. Edited by M.V. Volkov and G.M. Ter-Egiazarova, M., Medicine, 1983).

A known modified method of operation is Tuby (Surgical treatment of pronation-flexion contractures of the forearm and hand in patients with cerebral palsy. Methodical recommendations. Compiled by I.I. Mirzoyev, A.M. Nenko, LNIDOI named after G.I. Turner. L., 1980, p. .10), in which the round pronator is extended by the periosteal flap, cut off from the attachment site, is passed through the interosseous membrane around the radius and is fixed intraosseously through the canal distal to the previous attachment site.

The disadvantages of this method are the need to cut off the muscle from the place of attachment, the possibility of injury to the vessels of the interosseous membrane, the possibility of pinching the muscles in it.

A known method of double osteotomy of the radius (copyright certificate No. 1490018, 06/30/1989, A 61 B 17/56), which is adopted as a prototype.

The prototype has the following disadvantages: the operation seems unnecessarily traumatic due to the need for a double osteotomy of the radius, the pathological effect of spastic muscles in the form of round and square pronators is preserved, which reduces the functional effectiveness of the operation and increases the risk of relapse.

The task of the invention is to increase the effectiveness of surgical treatment of pronational contracture of the forearm with cerebral palsy.

The technical result achieved by the implementation of the proposed method is to increase the functionality of the upper limb by eliminating pronational contracture of the forearm due to corrective osteotomy of the radial bone with the simultaneous transformation of a round pronator into arch support without violating its integrity.

The task is achieved by the fact that a periosteal flap is cut out on the radial bone, which extends the tendon of the round pronator in the distal direction, it is separated from the cortical part of the radial bone without cutting off the attachment point, a transverse subperiosteal radial bone osteotomy is made, and the round pronator is moved through the created defect of the radial bone with palmar on the back side, while lengthening the lever action of muscle strength due to the level of osteotomy.

The proposed method is illustrated in figures 1-3.

Figure 1 shows a diagram of the first stage of the operation - cutting a periosteal flap on the radius, continuing in the distal direction the tendon of the round pronator;

figure 2 shows a diagram of the second stage of the operation - separation of the periosteal flap and tendon of the muscle of the round pronator and osteotomy of the radius;

figure 3 shows a diagram of the third stage of the operation - the periosteal flap and tendon of the round pronator through the defect of the radius from the palmar to the back side.

The drawings show: the radius 1, cut out periosteal flap 2, ulna 3, round pronator 4, osteotomy of the radius 5 (figure 2), defect of the radius 5 (figure 3).

The method is as follows.

A skin incision 10-15 centimeters long in the upper and middle third of the palmar surface of the forearm provides access to the round pronator at the site of its attachment to the radius. Two parallel sections (3-4 cm long and 0.5-1.0 cm wide) cut a periosteal flap 2 on the radius 1, extending in the distal direction the tendon of the round pronator 4 (Fig. 1).

The periosteal flap, together with part of the tendon of the round pronator and the muscle itself, is separated from the cortical part of the radius 1, not cutting off from the attachment point 2. In the middle third of the radius in the area of the periosteal flap, the periosteal transverse osteotomy 5 of the radius 1 is performed (Fig. 2).

The periosteal flap and tendon of the round pronator 2, which at this moment acquires the function of arch support, are carried out in the formed fissure 5 (Fig. 3). In this case, the integrity of the interosseous membrane is not violated.

Coronation of pronational contracture of the forearm is carried out, followed by radial bone metal osteosynthesis using the Kirschner spoke, the spoke from the Ilizarov apparatus or the osseous plate in the position of the achieved supination of the forearm. After hemostasis, the wound is sutured tightly.

Perhaps the addition of this operation with the myotomy of the square pronator with its cutting off from the lower third of the ulna 3.

Additional fixation is carried out by a plaster cast to the upper third of the shoulder for 1-1.5 months and stops after x-ray verification of the consolidation of the radius in the place of osteotomy. Then the metalwork is removed.

Further rehabilitation treatment is aimed at training the muscles of the forearm in new working conditions, creating a dynamic stereotype of supination of the forearm and hand.

The effectiveness of the proposed method for surgical treatment of pronational contracture of the forearm in cerebral palsy is due to the following fundamental provisions:

1. The operation is performed without cutting the tendon of the round pronator from the place of its attachment.

2. There is no need to conduct the tendon of the round pronator through the interosseous membrane with the risk of damage to the vessels and muscle infringement in it.

3. Due to the regulation of the length of the periosteal flap and the level of osteotomy, it becomes possible to vary the length of the working arm of the muscle and, therefore, the strength of its action.

4. Corrective osteotomy of the radius enhances the effect of the operation, the main purpose of which is to turn the round pronator into arch support without clipping the place of attachment of its tendon.

The method was tested in the surgical department of the MUZ City Children's Hospital of the city of Shakhty for 8 patients.

The invention is illustrated by the following clinical case.

Patient Ch., 14 years old, is observed with a diagnosis of cerebral palsy, hemiplegic form, spastic hemiplegia on the right, pronational contracture of the right forearm. Long-term conservative treatment using a wide range of physiotherapeutic methods, massage, exercise therapy, acupuncture, etc. proved ineffective. Indications for surgical treatment in connection with the loss of function of the upper limb are determined.

The operation was performed under general anesthesia. The position of the patient on the back, right upper limb on the side table. A skin incision 14 cm long in the projection of a circular pronator along the palmar surface of the forearm. The place of attachment of the tendon of the round pronator to the radius was exposed, and the periosteal flap 4 cm long and 1 cm wide was continued to extend this tendon in the distal direction. The flap along with part of the tendon and muscles were separated from the radius. At the border of the middle and lower third of the radial bone transverse subperiosteal osteotomy was performed. A periosteal flap was inserted into the resulting gap in such a way that the muscle acquired the function of arch support. The forearm is brought to the supination position, and fragments of the radius are retrograde fixed with a spoke drawn through the medullary canal from the Ilizarov apparatus with a diameter of 2 mm in the position of the achieved correction.

Performed myotomy of the square pronator in the usual way. Hemostasis, the wound is stitched tightly. An additional fixation was made with a plaster cast to the upper third of the shoulder. Operation time 1 hour.

In the postoperative period, he received analgesics, desensitizing drugs, symptomatic treatment, non-steroidal anabolic drugs, magnetotherapy, calcium and phosphorus preparations. The sutures were removed on the 10th day with the subsequent transfer of the plaster cast to the circular plaster cast. The result of the operation is confirmed by a control radiograph.

The plaster cast was removed and the needle was removed 1.5 months after radiological verification of reliable consolidation.

The recovery period and rehabilitation were carried out in the rehabilitation center "Dobrodeya" for children with cerebral palsy. In the treatment, wrist and forearm fixation was used, physical therapy, massage, acupuncture, microwave - microresonance therapy, phonophoresis and electrophoresis of drugs, electrical stimulation, paraffin therapy, vitamin therapy, biogenic stimulants.

The treatment resulted in a significant increase in supination of the forearm and hand, as well as a partial restoration of the function of the right upper limb.

Claims (1)

A method for surgical treatment of pronational contracture of the forearm in cerebral palsy by transverse corrective osteotomy of the middle third of the radius, supination of the forearm followed by fixation of fragments, characterized in that the periosteal flap along with the attachment of the tendon of the round pronator and the muscle itself is separated from the cortical part of the radius the flap area performs subperiosteal osteotomy of the radius, the periosteal flap and tendon round are made into the formed gap th pronator, after which the contracture is corrected and fragments are fixed.

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