RU2288662C2 - Method for operative treatment at neurogenic contracture of fingers - Google Patents

Abstract

FIELD: medicine, traumatology.

SUBSTANCE: the present innovation deals with treating aftereffects of affected motor branches of median and ulnar nerves. Incision should be made upon volar surface in projection of metacarpal-phalangeal articulations to be fixed with needles at the angle of 150°, at the border of median and distal thirds of metacarpal bones it is necessary to cross a tendon of a surface flexor of fingers to be longitudinally dissected, in distal third of metacarpal bones one should form canals in cross-sectional direction to apply split tendinous parts into the canals to be sutured with other ends of this tendon, cross tendinous pedicles of surface flexor of fingers, their proximal parts should be fixed to lateral bundles of apparatus' extensor that prevents the relapse of deformation.

EFFECT: higher efficiency of therapy.

1 dwg, 1 ex

Description

The invention relates to medicine, in particular to traumatology in the treatment of neurogenic contracture of the fingers of the hand that occurs after damage to the motor branch of the ulnar nerve.

Numerous methods are known for surgical treatment of neurogenic contractures of the fingers of the hand after damage to the motor branch of the ulnar nerve resulting from this atrophy of the interosseous and vermiform muscles of the hand and leading to hyperextension in the metacarpophalangeal joints of the fingers and secondary flexion in the interphalangeal joints. The operations used to correct the "clawed paw" are based on the principle of ensuring stability in the metacarpophalangeal joints. This is the famous operation proposed by Bennel (Bunnell S: Tendon transfers in the hand and forearm, AAOS Instr Course Lect 6: 106, 1949), in which the tendon of the superficial flexor of the finger is split into 4 bundles to eliminate hyperextension in the metacarpophalangeal joints, the latter are performed into the channels of the vermiform muscles on the extensor surface and are sutured to the lateral bundles of the extensor apparatus. This operation can only be used for isolated nerve damage. The Zancolli operation is widely used (Zancolli EA: Surgery for the quadriplegic hand with active, strong wrist extension preserved: a study of 97 cases, Clin Orthop 112: 101, 1975), the essence of which is to shorten the anterior capsule of the metacarpophalangeal joints, then there is a capsulodesis. This operation also has some drawbacks: in some cases, the scar is overstretched to the joints of the joint capsule and the extensor contracture of the fingers recurs, the immobilization is quite long, the adhesion process between the capsule and flexor tendons may develop.

In the operation proposed by Fowler (Fowler SB: Mobilization of metacarpophalangeal joints, J Bone Joint Surg 29: 193, 1947), to create a tenodesis, a free tendon graft is performed through the block at the level of the back of the wrist. At this level, its proximal end is fixed. The distal portion of the graft splits lengthwise, and both ends are held under the metacarpal ligaments in each intercarpal space and are fixed to the lateral bundles of the extensor apparatus. Among the shortcomings, it can be noted that free tendon grafts are prone to degeneration and after this operation relapses of extensor contracture of the metacarpophalangeal joints are possible.

Thus, the use of known methods of eliminating hyperextension in the metacarpophalangeal joints of the fingers is characterized by either insufficient effectiveness or increased invasiveness of treatment.

The technical solution of the invention is to increase the effectiveness of treatment without a significant increase in its injuries.

The claimed technical effect is achieved by the fact that it is possible to eliminate hyperextension in the metacarpophalangeal joints of the fingers of the hand (tenodesis is created) with neurogenic contractures without causing significant damage to other functional structures of the hand.

The compliance of the technical solution with the criterion of "novelty" is determined by the absence in the prior art of an identical technical solution to achieve the claimed result.

Compliance with the criterion of "industrial applicability" is determined by the effectiveness of restoration of the function of the hand with neurogenic contractures of the fingers of the hand that occur after damage to the motor branch of the ulnar nerve, and the willingness to move on to the widespread implementation of the proposed method, for which it is advisable to obtain patent protection of a new development.

In our proposed method, to create a tenodesis, use the distal portion of the tendon of the superficial flexor of the fingers with transossal fixation of it to the metacarpal bone. Additional fixation of the legs of the tendon of the superficial flexor to the lateral bundles of the extensor apparatus of the finger improves active extension in the interphalangeal joints of the fingers. To do this, a figured incision (S-shaped) is performed along the palmar surface of the hand in the projection of the metacarpophalangeal joints. The metacarpophalangeal joint is fixed with Kirschner spokes at an angle of 150 degrees. The tendon of the superficial flexor of the fingers stands out. At the border of the middle and distal third of the metacarpal bones, they intersect transversely. A longitudinal dissection of its distal section for 2-3 cm is performed. Using a drill and a thin drill, a channel in the transverse direction is formed in the distal third of the metacarpal bone 2. One of the ends of the split portion of the tendon of the superficial finger flexor is drawn into the canal using the Deschan needle and is lapped to the other end with interrupted sutures on the opposite side. The incision extends along the palmar surface of the finger to the head of the main phalanx. At this level, the legs of the tendon of the superficial flexor of the fingers intersect 1. Then their proximal sections are fixed with interrupted sutures to the lateral bundles of the extensor apparatus. Thus, the tenodesis of the metacarpophalangeal joint is formed (drawing). An additional immobilization with a plaster cast is carried out. Immobilization is removed after 3 weeks, and the patient begins to exercise therapy.

The goal is achieved, the method is highly efficient, without increasing the invasiveness of the intervention. The increase in the effectiveness of the operation is explained by the fact that an earlier start of movements is possible (after 3 weeks). The strength of the suture of the tendons with this method is significantly higher than with capsuloraphy of the joint. Suturing the legs of the superficial flexor of the fingers to the lateral bundles of the extensor apparatus of the finger is an additional factor preventing the relapse of extensor contracture in the metacarpophalangeal joint.

The flexion in the metacarpophalangeal joint remains in the range from 150 to 90 degrees. The effectiveness of the treatment according to the proposed method increases, since in a shorter time, the function of the brush is restored and the patient returns to work

Clinical example: Patient S., 37 years old, was admitted to the 16th department of RosNIIITO on an emergency basis with a diagnosis of traumatic separation of the right forearm. In RosNIIITO them. RR Vredena emergency ambulance performed the right forearm. After 10 months, the patient was hospitalized in a planned manner with a diagnosis of neurogenic contracture of the fingers of the right hand. The patient complained of pronounced extension of the fingers in the metacarpophalangeal joints, the inability to compress the fingers into a fist, and a decrease in the strength of the right hand. An operation was performed according to the described method with fixation of the metacarpophalangeal joints of 2-5 fingers with Kirschner spokes and a plaster cast for up to 3 weeks. After a course of rehabilitation treatment, the active flexion of the fingers of the hand was almost completely restored without pain, the grip force was restored. Examined after 1 year: the effect of the operation is preserved in full.

Claims (1)

A method of surgical treatment for neurogenic contracture of the fingers of the bone (“clawed paw”), which consists in creating a tenodesis of the metacarpophalangeal joints of 2-5 fingers, characterized in that the incision is performed on the palmar surface of the hand in the projection of the metacarpophalangeal joints, which are fixed with needles at an angle 150 °, at the border of the middle and distal third of the metacarpal bones, the tendon of the superficial flexor of the fingers crosses, cut it longitudinally, in the distal third of the metacarpal bones form channels in the transverse direction, split tendon and sutured to the other ends of the tendon, cross legs tendon flexor surface of fingers, the proximal portions thereof are fixed to the side beam extensor mechanism.