RU2328242C2 - Method of transosseous osteosynthesis of disphysial forearm damages and related device - Google Patents

Abstract

FIELD: medicine; traumatology.

SUBSTANCE: ulnar and radial bone fragments are separately fixed. Transosseous osteosynthesis device is initially applied to ulnar bone, and then identical transosseous osteosynthesis device is applied to radial bone. Device contains supports connected by threaded rods, reposition unit and rods-screws with clamps. Proximal and distal supports are 1/6 ring-shaped. Intermediate supports are 1/3 ring-shaped. Rods-screws on proximal and distal supports are fixed by means of arms with threaded aperture. Each of intermediate supports has reposition unit which includes detachable threaded rod in which central part element with interperpendicular apertures one of which is designed for fastening by means of rod-screw nuts. Detachable threaded rod is connected to intermediate support by arms.

EFFECT: fixed forearm rotation movement restoration; reduced risk of contracture development and reduced treatment time.

2 cl, 1 ex, 7 dwg

Description

The present invention relates to medicine, namely to traumatology, and can be used in the treatment of open and closed fractures of both bones of the forearm, fused in the wrong position, false joints, diaphyseal defects of the ulna and radius.

A known method of treating diaphyseal fractures of both bones of the forearm, the essence of which is that the base support of the external fixation apparatus in the form of a ring is applied to the distal fragments of both bones. Then, on the proximal fragments of both bones of the forearm, a cantilever spoke is carried out, which is fixed in the spokes of the external support of the apparatus, made in the form of a 3/4 ring. Proximal and distal to the fracture site, two intermediate external supports of the apparatus are installed in the form of rings, to which distal and proximal fragments of both bones are fixed using cantilevered transosseous elements and transsegmental spokes, each fragment being separate. The technology of fixation of fragments provides for the possibility of separate reposition [1].

However, the known technology eliminates the possibility of rotational movements of the forearm, which leads to persistent contracture in the proximal and distal radiolactic joints, retraction of the interosseous membrane. Conducting through the radial and ulnar bones through the radius and ulna in the distal intermediate external support leads to the formation of additional fixation points, which, in turn, also leads to contractures.

Closest to the proposed method is transosseous osteosynthesis of fresh closed comminuted fractures of both bones of the forearm. To separately control the distal fragments of the radius and ulna bones, the needles are drawn through them separately, each of the bone fragments being fixed to the main and additional supports of the Ilizarov apparatus so that these fragments can be manipulated in isolation. In the proximal and distal base supports fix transsegmental transosseous elements held through both bones [2].

However, the use of the well-known technology for fixation of fragments of the radius and ulna does not provide the possibility of rotational movements of the forearm at the treatment stages, which subsequently leads to persistent contracture in the proximal and distal radiolactic joints and retraction of the interosseous membrane. The use of only transsegmental fixation elements, conducted through the radius and ulna, fixes muscle tissue, which contributes to the occurrence of contractures of the forearm. The fixation time in the apparatus is 65-106 days, the average recovery time after 90 days from the date of operation.

A device is known for transosseous osteosynthesis of both bones of the forearm, consisting of a distal, proximal and two intermediate external support elements interconnected by threaded rods, while the proximal base support is made in the form of an arc 3/4 of the ring, the remaining supports are ring-shaped. To the distal and proximal base supports are fixed rod transosseous elements, which are fixed in external supports using brackets with an internal threaded hole. Cantilever and transsegmented knitting needles are fixed in spoke fixators fixed in the external supports of the apparatus [3].

The known device eliminates the possibility of performing rotational movements in the forearm.

Closest to the proposed is a device for fixing bone fragments with fresh closed injuries of both bones of the forearm, which contains the base and intermediate external supports of the Ilizarov apparatus, connected by threaded rods. The proximal external base support is made in the form of 1/2 ring. On the distal base and intermediate external supports of the apparatus, brackets with an internal threaded hole and spoke fixators are installed, in which transsegmented through the distal fragments of both bones of the forearm of the spoke are fixed. Specific fixators are installed on the proximal base and intermediate external supports of the apparatus, in which transsegmental segments through the proximal fragments of both bones of the forearm of the needle are fixed [4].

A disadvantage of the known design is that there is no possibility of performing rotational movements of the radius relative to the ulna.

Based on the current level of technology and designs for the treatment of injuries of both bones of the forearm, as well as to eliminate the shortcomings existing in this area, the task was set: to reduce the treatment time by providing rotational movements of the forearm during the fixation period and to exclude the development of contractures in the proximal and distal radiocarpal joints.

The problem is solved as follows.

The method of transosseous osteosynthesis of diaphyseal fractures of both bones of the forearm includes the fixation of fragments by the transosseous external fixation apparatus and the possibility of comparing them in time. What is new in solving this problem is that the fixation of fragments of the ulnar and radius bones is carried out separately, with the external fixation apparatus being initially placed on the ulna and then the identical external fixation apparatus on the radius.

Regarding the device for performing transosseous osteosynthesis of diaphyseal fractures of the forearm bones, it is new that the supporting elements of the proximal and distal sections are made in the form of a 1/6 ring sector and the intermediate supports are made in the form of a 1/3 ring sector. In this case, the screw rods on the proximal and distal supports are fixed using brackets with a threaded hole, and each of the intermediate supports has a reposition unit, including a remote threaded rod, through brackets connected to the intermediate support, and an element with mutually perpendicular holes, in one of which is fixed screw rod.

We explain the significant distinguishing features of the proposed method of transosseous osteosynthesis and apparatus for its implementation.

Separate fixation of fragments of the ulnar and radius bones, the initial application of the external fixation apparatus on the ulnar bone, and then the identical external fixation apparatus on the radius, allows for precise, simultaneous, intraoperative reposition of fragments of both bones and restoration of the limb axis.

To implement the method, an apparatus was developed for transosseous osteosynthesis of damage to the forearm bones, in which the supporting elements of the proximal and distal sections are made in the form of a 1/6 ring sector and the intermediate supports are made in the form of a 1/3 ring sector, which makes it possible to carry out rotational movements in the forearm, s an amplitude sufficient to prevent the occurrence of contractures in the proximal and distal radiolbow joints.

Design features of the reposition unit provide:

1. remote threaded rod with brackets having threaded holes - the ability to eliminate the displacement of fragments of the ulnar and radius bones in the frontal plane;

2. an element with mutually perpendicular holes, in one of which a screw-rod is fixed, allows reposition of fragments of the radius and ulna in the frontal and sagittal planes.

The patent studies on subclasses А61В 17/60, 17/58, as well as the analysis of scientific and medical information reflecting the current level of technology for treating injuries of both bones of the forearm and transosseous osteosynthesis apparatuses, did not reveal identical developments. Thus, the proposed method of treatment and apparatus for its implementation are new.

The interconnection and interaction of the essential techniques of the method and the device for its implementation ensure the achievement of a new medical result in solving the problem, namely: reducing treatment time by providing rotational movements of the forearm during the fixation period and eliminating the development of contractures in the proximal and distal radiological and elbow joints. Thus, the proposed technical solution has an inventive step.

The proposed method for the treatment of injuries of bones of the forearm and apparatus for its implementation can be widely used in clinical practice.

The essence of the proposed "Method of transosseous osteosynthesis of diaphyseal injuries of the bones of the forearm" is as follows.

With fresh injuries, skeletal traction is initially performed to eliminate gross displacements of bone fragments; in other cases, an external fixation apparatus is applied.

Initially, an external fixation apparatus is mounted on the ulnar bone, then an identical apparatus is placed on the radius. Fragments of the radial and ulnar bones are fixed with transosseous elements, while initially the screw rods are passed through the proximal and distal ulnar fragments, which are sequentially fixed to the supports of the external fixation apparatus, and then the screw rods are passed through the proximal and distal radial fragments, which also sequentially fixed to the supports of the external fixation apparatus. The fixation period in the device is 60-70 days, the restoration of disability on average after 70 days.

To implement the method, an apparatus was developed for transosseous osteosynthesis of both bones of the forearm, the essence of which is illustrated by drawings, where:

- figure 1 is a General view of the device;

- figure 2 - reposition unit with a rod-screw;

- figure 3 - bracket with a rod-screw;

- figure 4 - scheme of the apparatus on both bones;

- figure 5 - x-ray of the left forearm of a patient M. before treatment;

- Fig.6 is a radiograph of the left forearm of a patient M. during fixation in AVF;

- Fig.7 - x-ray of the left forearm of a patient M. after dismantling the AVF.

The device for transosseous osteosynthesis of diaphyseal injuries of the bones of the forearm, consists of: external supports 1, 2, 3 and 4, interconnected by threaded rods 5. The proximal and distal base supports 1 and 4 are made in the form of a sector 1/6 of the ring, in each of them with the help of brackets 6 with a threaded hole 7, the screw-rod 8 is fixed. The intermediate supports 2 and 3 are made in the form of a sector 1/3 of the ring, in each of them with the help of the reposition unit 9 (figure 2) the rod-screw 8 is fixed. Reposition nodes 9 (figure 2) include a remote threaded rod 10, at the ends of which two brackets 6 are fixed with an internal threaded hole 7. Using brackets 6, reposition nodes 9 are fixed to external intermediate supports 2 and 3. In the central part of the remote threaded rod 10, an element 11 with mutually perpendicular holes is fixed, one of them is fixed the screw-rod 8 perpendicular to the remote threaded rod 10 with the help of nuts 12.

Apply the proposed method and apparatus for transosseous osteosynthesis as follows.

After carrying out skeletal traction for 2-5 metacarpal bones and the ulnar process of the ulna, four rod-screws 8 (two to the proximal fragment and two to the distal fragment) are successively carried out at the angle of 90 ° to the longitudinal axis of the bone in the sagittal plane. Two rods-screws 8 using brackets 6 are fixed to the external supports 1 and 4 (distal and proximal). The rest of the screw rods 8 are fixed in the holes of the elements 11 mounted on the remote threaded rods 10, which are connected to the intermediate supports 2 and 3 using the brackets 6. The screw rod 8 and the element 11 on the remote threaded rod 10 are fixed with nuts 12. External supports 1, 2, 3, 4 are connected in series with each other by threaded rods 5. Reproduce fragments of the ulna as follows: using threaded rods 5 located between the distal and proximal intermediate supports 2 and 3, due to These displacements of the screws 12, distraction produce 10-15 mm (depending on the displacement along the length of the fragments). Then, using reposition units 9, if it is necessary to reposition fragments in the sagittal plane, the screw-rod 8 is moved in element 11 by moving the nuts 12. If it is necessary to eliminate the displacement of the fragments in width, element 11 is displaced in the frontal plane along the remote threaded rod 10 due to the movement of nuts 12. The device is stabilized.

Four fragments of a screw 8 are successively carried out into fragments of the radius bone (two into the proximal fragment and two into the distal fragment) at an angle of 90 ° to the longitudinal axis of the bone in the sagittal plane. Each rod-screw 8 using brackets 6 and reposition unit 9 is fixed to external supports 1, 2, 3, 4, distal and proximal to supports 1 and 4 (sectors 1/6 of the ring), intermediate to supports 2 and 3 (sectors 1 / 3 from the circumference of the ring of the Ilizarov apparatus). External supports 1, 2, 3, 4 are sequentially connected to each other by threaded rods 5. Reposition of fragments of the radius bone is performed in a manner similar to that described above for reposition of the ulna. The device is stabilized. Skeletal traction is dismantled.

For chronic injuries, the reposition of fragments is carried out in time as follows: with the help of threaded rods 5 located between the distal and proximal intermediate supports 2 and 3, 10-15 mm are distracted by moving nuts 12 along them (depending on the displacement of the fragments along the length) discretely at 2-2.5 mm per day. Then, using reposition units 9, discretely 1 mm per day, reposition of fragments is performed - in the sagittal plane, the screw-rod 8 is moved in the element 11 by moving the nuts 12, in the frontal plane, the element 11 is moved along the remote threaded rod 10 due to the movement of the nuts 12. After performing the reposition maneuver, the apparatus is put into fixation mode.

The essence of the proposed "Method of transosseous osteosynthesis of diaphyseal injuries of the bones of the forearm and apparatus for its implementation is illustrated by a clinical example.

Patient M., 17 years old, was admitted to the clinic GU SC RVH VSNS SB RAMS with complaints of pain in the right wrist joint, the inability to fully use the right hand and right forearm.

Objectively: Asymmetry of the forearms due to atrophy of soft tissues on the right throughout. The axis of the limb is changed - in the middle third of the forearm, the angle is open to the back surface of the forearm. Relative shortening of the limb - 0.5 cm due to angular deformation. Movements in adjacent joints are limited: in the elbow - 125/30/0, in the wrist - 30/0/30, rotation of the forearm - 30/0/0.

There are no vascular, motor, sensory disorders in the distal extremities.

On the roentgenogram of the right forearm at the level of the middle third of the diaphysis, there is a violation of the integrity of both bones and angular deformation of 170 ° - the ulna, 172 ° - the radius.

Diagnosis: Fractures of both bones of the right forearm consolidating in the wrong position. Combined contracture of the right elbow and wrist joints, rotational contracture of the forearm.

An operation was performed according to the proposed technology using an apparatus for its implementation.

After carrying out skeletal traction for 2-5 metacarpal bones and the ulnar process of the ulna, four screw rods 8 (two to the proximal fragment and two to the distal fragment) were successively carried out at the angle of 90 ° to the longitudinal axis of the bone in the sagittal plane. Each rod-screw 8 with brackets and reposition unit 9 is fixed to external supports 1, 2, 3, 4 (distal and proximal to sectors 1/6, intermediate to sectors 1/3 of the circumference of the ring of the Ilizarov apparatus). External supports are connected in series by threaded rods 5. The device is stabilized.

Similarly, four screw rods (two into the proximal fragment and two into the distal fragment) were sequentially drawn into fragments of the radius bone at an angle of 90 ° to the longitudinal axis of the bone in the sagittal plane. Each rod-screw 8 with brackets 6 and reposition unit 9 is fixed to external supports (distal and proximal to sectors 1/6, intermediate 1/3, from the circumference of the ring of the Ilizarov apparatus). External supports are connected in series by threaded rods 5. The device is stabilized. Skeletal traction dismantled.

The residual displacement of the bone fragments of both bones of the left forearm in the external fixation apparatus was eliminated in time as follows: by means of threaded rods 5, by moving nuts 12 along them, between intermediate external supports 2 and 3, in devices on the radius and ulna bones, discreetly 2 mm per day performed 10 mm distraction. Then, in the apparatus on the ulnar bone with the help of the reposition unit 9, fixed in the distal intermediate support, discretely 1 mm per day, the reposition of the distal fragment was performed - in the sagittal plane, the screw-rod 8 was brought closer to element 11 by moving the nuts 12. At the same time in the apparatus on the radius using repositional nodes 9 fixed in the distal and proximal intermediate supports 2 and 3, discretely 1 mm per day, reposition of fragments of the radius in the frontal and sagittal planes was performed a screw rod 8 and moving the element 11 in the frontal plane along the remote threaded rod 10 due to the movement of nuts 12. After performing the reposition maneuver, the device is switched to the fixing mode.

On the roentgenogram, the deformity is eliminated, the standing of the bone fragments is satisfactory, the bones of the forearm are fixed by an external fixation apparatus.

The postoperative period without complications. Movement in the elbow, wrist joints, fingers of the hand is allowed from the first day, from the 3rd day after the operation, exercise therapy began. On the 12th day after the operation in satisfactory condition, the patient was discharged for outpatient treatment. 74 days after the operation, the external fixation apparatus was dismantled. The patient freely uses the right upper limb, no complaints, range of motion in adjacent joints: elbow - 160/5/0, wrist - 40/0/50, rotation of the forearm 60/0/70; the patient's ability to work is fully restored. The anatomical and functional result of treatment according to the Mattis-Luboschitz-Schwarzberg system [4] is regarded as good.

Thus, the proposed “Method for transosseous osteosynthesis of diaphyseal injuries of the bones of the forearm and apparatus for its implementation” in comparison with the known technologies and designs for their implementation allowed to reduce the treatment time by reducing the fixation time (by 10-14 days) and preserving the rotation of the forearm in the period of limb fixation in the apparatus and the exclusion of the development of contractures in the proximal and distal radiolbow joints (for 10 days).

Information sources

1. Solomin L.N. Fundamentals of transosseous osteosynthesis apparatus G.A. Ilizarov: Monograph. - SPb. LLC MORSAR AV, 2005, - p.200-202.

2. A.S. No. 1572581 of the USSR, MKI ⁶ A61B 17/56. A method for the treatment of diaphyseal fractures of the forearm bones / G.A. Ilizarov, S.I. Shved, K.U. Kudzaev.

3. Combined transosseous osteosynthesis of diaphyseal fractures of the forearm bones. Manual for doctors. - SPb. NIIITO them. P.P. Vredena, 2004, p. 27.

4. Shvetsov V.I., Shved S.I., Sysenko Yu.M. Transosseous osteosynthesis in the treatment of comminuted fractures. - Kurgan - 2002, p.137.

5. Shvetsov V.I., Shved S.I., Sysenko Yu.M. Transosseous osteosynthesis in the treatment of comminuted fractures. - Kurgan - 2002, p. 243-244.

Claims (2)

1. The method of transosseous osteosynthesis of diaphyseal fractures of the forearm bones, including fixation of fragments by the apparatus for transosseous osteosynthesis after comparing them, characterized in that the fixation of fragments of the ulnar and radial bones is performed separately, while initially the apparatus for transosseous osteosynthesis is applied to the ulnar to the ulnar transosseous osteosynthesis on the radial bone. 2. An apparatus for transosseous osteosynthesis of fractures of the forearm bones, containing supports connected by threaded rods, reposition units and screw rods with clamps, characterized in that the proximal and distal supports are made in the form of a sector 1/6 of the ring, the intermediate supports are made in the form of sector 1 / 3 rings, while the screw rods on the proximal and distal supports are fixed using brackets with a threaded hole, and each of the intermediate supports has a reposition unit, which includes a remote threaded rod, in the central part of which is fixed to an element with mutually perpendicular holes, one of which is intended for fastening with the help of nuts of a screw rod, an external threaded rod is connected to the intermediate support by means of brackets.

Images