RU2513594C1 - Method for reduction of fragments in closed intramedullary osteosynthesis of humeral neck fractures - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: minimally invasive transdeltoid approach, opening into a subacromial space and dissection of a rotatory cuff with a long two-centimetre incision from an edge of a greater tubercle to the centre of a humeral head; an EOP-assisted awl is introduced into the humeral head from the greater tubercle to the centre of the head downright and rotated downright to eliminate an incomplete dislocation; the greater tubercle is reduced; and the head is directed in the position optimal for introducing a nail wherein the head is fixed to an articular process of a shoulder blade using two pins introduced through a lesser tubercle from the front and through the greater tubercle at the backside of the canal from a rod canal formed in the geometrical centre of the humeral head. The head is matched with a distal fragment, and the rod is introduced into the canal, and the head, tubercles and diaphysis are fixed using altitude clamps. The temporary pins are removed thereafter.

EFFECT: method enables matching the humeral fragments, providing the optimum conditions for the intramedullary osteosynthesis ensured by the reliable temporary head fixation.

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Description

The invention relates to medicine, namely to traumatology and orthopedics, and is used in the surgical treatment of fractures of the proximal humerus: surgical, anatomical neck, and also accompanied by fractures of the tubercles.

Intramedullary osteosynthesis of a fracture of the surgical neck of the humerus has an important advantage, consisting in the low invasiveness of the implant. This allows you to maximize the blood supply to the fragments and reduce the likelihood of developing aseptic necrosis with three- and four-fragment fractures. However, short fragments of the head and tubercles, with the tendons of rotator muscles attached to them, are easily displaced, which creates significant difficulties both in reposition and in the introduction of structural elements - the shaft and locking screws, in which unpredictable displacement of intermediate fragments is possible. This can lead to incorrect reposition, an increase in the duration of the operation, with frequent repetition of repositional manipulations with the introduction of instruments and implants, which increase the invasiveness of the operation, and its main advantage is eliminated - preservation of periosteal blood supply of the fragments.

A known method [6], which consists in the closed comparison of fragments and the introduction of an intramedullary rod through the articular surface of the head into the channel of the diaphysis and fixing the tubercles, head and diaphysis with locking screws. The disadvantages of the operation are the technical difficulties of simultaneously comparing movable fragments of the head and tubercles, which, when a nail and blocking screws are inserted, repel each other, are mutually displaced and prevent a correct comparison, requiring a repeated repetition and an increase in the duration of surgery [2, 3, 4, 6, 7 ].

The closest in technical essence and functional purpose is the method of percutaneous fixation of fragments of the entire proximal shoulder with knitting needles [5, 9], which allows to preserve blood supply to the fragments of the proximal humerus as much as possible. However, the described technique for reposition of fragments in comminuted fractures of the head and neck of the shoulder is technically complex, and the result of the execution directly depends on the experience of the surgeon. The disadvantages of this method are: the complexity of the closed manual reposition, and, as a consequence, the duration of the intervention; the need for multiple images of X-ray image intensifier tubes, which entails an increase in the X-ray load on the patient and medical staff, as well as the use of unstable metal structures in contact with the external environment, which entails an increased risk of migration with loss of fixation and a possible increase in purulent septic complications. However, the experience gained using this method allows the use of certain elements — fixation with the needles of the head — as a temporary, stepwise measure during a more complex operation of intramedullary osteosynthesis.

The technical result of the invention is the comparison of fragments of the humerus due to reliable temporary fixation of the head and providing optimal conditions for intramedullary osteosynthesis: effective reduction with low trauma and preservation of the vessels feeding the head.

Using this technique allows you to solve several problems.

1. To reduce the duration and morbidity of the osteosynthesis of a fracture of the proximal humerus due to the maximum reduction in the number of manipulations.

2. To increase the accuracy of reposition by dividing it into the reposition stage and fixing fragments of the proximal humerus.

3. The introduction of a reponosal awl into the head of the humerus (in the direction from the large tubercle to the center of the head from top to bottom) allows eliminating subluxation with minimal trauma and high ergonomics, lowering the large tubercle and orienting the proximal section to the optimal position for nail insertion.

4. Fixing the head to the articular process of the scapula with two spokes in front and behind the proposed canal under the nail allows you to temporarily stabilize fragments of the articular end of the humerus and compare the diaphyseal fragment with simple manipulation without the risk of displacement of the epiphyseal fragments, which makes reposition reliable and predictably effective.

5. The introduction of an intramedullary rod into the proximal humerus fixed to the articular process, along the formed channel, avoids the unpredictable displacement of fragments.

The result of the invention is achieved in that after minimally invasive transdeltoid access, entry into the subacromial space and dissection of the rotator cuff by a longitudinal two-centimeter incision from the edge of a large tubercle to the center of the head, an awl is inserted into the head in the direction from the large tubercle to the center of the head from top to bottom. and by turning the awl from top to bottom, they eliminate the subluxation, lower the large tubercle and orient the head to the optimal position for introducing the nail, in which it is temporarily fixed its comfort to the articular process of the scapula with two knitting needles, which is inserted through the small tubercle in front and through the large tubercle behind the canal under the rod, which is formed in the geometric center of the humerus head, then the distal fragment is compared with it and the rod is inserted into the canal with fixation from the head , tubercles and diaphysis blocking screws, after which the temporary spokes are removed.

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 “inventive step” was determined by the fact that our solution does not follow explicitly from the prior art, and also by the fact that the effect achieved by the claimed solution is revealed as a result of a targeted search by the inventors themselves.

Compliance with the criterion of "industrial applicability" is determined by the safety and effectiveness of the reproduction of the proposed method. For widespread implementation of the proposed method, the applicant seeks patent protection of a new development.

The drawings show:

Figure 1. Surgical access. View from above. Access in relation to the channel in the head of the shoulder, where 1 is the head of the humerus; 2 - the humerus (distal fragment and diaphysis); 3 - skin incision; 4 - subacromial space; 5 - incision on the rotator cuff; 6 - a large tubercle of the humerus; 14 - channel under the nail (portal).

Figure 2. Closed reposition of fragments. Front view. The introduction of an awl for repositioning the head and large tubercle, where 1 is the head of the humerus; 2 - the humerus (distal fragment and diaphysis); 4 - subacromial space; 6 - a large tubercle of the humerus; 7 - awl; 8 - direction of rotation with an awl of a head with a large tubercle; 9 - small tubercle.

Figure 3. Reposition with an awl of fragments of the head with the reduction of the tubercle and the elimination of displacement, front view, where 1 is the head of the humerus; 2 - the humerus (distal fragment and diaphysis); 6 - a large tubercle of the humerus; 7 - awl; 8 - direction of movement with an awl of a head with a large tubercle; 9 - small tubercle; 14 - channel under the nail (portal).

Figure 4. Temporary fixation of fragments of the humeral head to the articular process with knitting needles (frontal projection, rear view, on which the displacement of the distal fragment is not eliminated), where 1 is the head of the humerus; 2 - the humerus (distal fragment and diaphysis); 4 - subacromial space; 6 - a large tubercle of the humerus; 9 - small tubercle; 10 - articular process of the scapula; 11 - spoke, performing temporary fixation of the proximal fragment, made from a large tubercle; 12 - spoke, performing temporary fixation of the proximal fragment, made from a small tubercle; 14 - channel under the nail (portal); 15 - projection of the position of the awl after its removal.

Figure 5. Temporary fixation of fragments of the humeral head to the articular process with knitting needles (top view, semi-axial projection, on which the displacement of the distal fragment is eliminated), where 1 is the head of the humerus; 2 - the humerus (distal fragment and diaphysis); 6 - a large tubercle of the humerus; 9 - small tubercle; 10 - articular process of the scapula; 11 - spoke, performing temporary fixation of the proximal fragment, made from a large tubercle; 12 - spoke, performing temporary fixation of the proximal fragment, made from a small tubercle; 13 - geometric center of the head; 14 - channel under the nail.

6. Radiography (direct projection) of the right humerus at the end of osteosynthesis (after removal of temporary knitting needles). Reposition and fixation of fragments of the head and diaphysis with screws is shown, where 1 is the head of the humerus; 2 - the humerus (distal fragment and diaphysis); 6 - a large tubercle of the humerus; 10 - articular process of the scapula; 16 - rod (nail), 17 - locking screws.

7. Radiography (direct projection) of the right shoulder joint of patient L. upon admission to the clinic RNIITO.

Fig. 8. Computed tomogram (3D - reconstruction) of the right shoulder joint of patient L. upon admission to the clinic RNIITO.

Fig.9. Postoperative radiography (direct projection) of the right humerus of patient L. with maximum internal rotation.

The method of closed intramedullary osteosynthesis of fractures of the proximal part 1 of the humerus is as follows. After performing minimally invasive transdeltoid access 3, entering the subacromial space 4, the tendons 5 of the supraspinatus and subscapularis muscles are sharply separated by a linear incision 2 cm from the edge of the large tubercle 6 (when it is intact) in the ascending direction to the apex and center 13 of the head of the humerus 2. When three-fragment (according to Neer classification) fractures of the proximal humerus, a fragment of a large tubercle, located on the tendon of the supraspinatus muscle, often moves into the subacromial space 4 in the direction supraspinatus fossa. In this case, the rotational cuff is dissected in the proximal direction.

To reposition the head 1 and the large tubercle 6, the awl 7 is introduced from the projection point of the large tubercle in the direction of the geometric center 13 of the head. Further, in the case of a front dislocation or subluxation of the head, displacements are eliminated by turning 8 awl 7 by the handle in the frontal plane, in the direction from top to bottom, and in the sagittal - from front to back. If, by the nature of the fracture, there is a posterior dislocation or subluxation, it is necessary to turn the awl 7 in the frontal plane in the direction from top to bottom, and in the sagittal plane from back to front, reposition the head 1. When displacing the large tubercle 6 into the subacromial space 4, a pointed awl is introduced above its apex through the tendon of the supraspinatus muscle and the initial anatomical bed of the tubercle in the head of the shoulder 1. Then establish a close to the anatomical and physiological position of the head 1 relative to the articular process of the scapula 10 with retrovers by 30-35 degrees. Then, using the Kirschner needle 12, the head is temporarily fixed to the articular surface of the scapula through the region of the small tubercle 9.

Then bring down the large tubercle 6 by turning 8 the awl 7 from top to bottom and fix it with another Kirschner spoke 11 through the head 1 of the humerus into the articular process of the scapula 10 with a 3-4 mm exit from the cortical layer on the dorsal and costal surface of the scapula. In this case, the entry points of the spokes 11 and 12 are selected so that the distance between them is more than 20 mm, and they pass in front and behind the proposed channel 14 for introducing the rod 16. The awl is removed 15.

Reposition and retention of the diaphysis of the humerus 2, relative to its proximal part 1, is performed using conventional techniques.

Under the image intensifier tube, a channel 14 is formed for the introduction of the rod 16, alternately drilling both fragments (1 and 2) and forming a portal to the required diameter of the rod 16.

Then, under fluoroscopic control, the rod 16 is inserted into the channel 14 with the fixation of the head 1, tubercles 6 and 9 and the diaphysis of the humerus with blocking screws 17.

Clinical example. Patient L., 54 years old. Injury (low energy) received in everyday life. Delivered by an ambulance team to the FBSU RNIITO them. P.P. Damaged with a diagnosis of: Closed comminuted fracture of the proximal right humerus with displacement of fragments. X-ray upon admission (Fig.7). In order to clarify the diagnosis, standing, and the nature of the displacement of the fragments of the patient, computed tomography of the right shoulder joint was performed (Fig. 8). On the 2nd day the patient underwent surgery: a closed reposition of fragments according to the proposed method, intramedullary osteosynthesis of the proximal section with a rod with blocking (Fig.6). To clarify the position of the locking screws in the proximal section, on the second day of the postoperative period, a direct x-ray was performed with maximum internal rotation of the shoulder (Fig.9).

At the control examination, 1.5 months after the operation, consolidation of the proximal part of the right humerus was achieved. When examined after 4 months, the patient, against the background of the absence of clinical and radiological signs of aseptic necrosis of the humeral head, there was a complete restoration of the function of the shoulder joint.

Bibliography

1. Wave A.A., Vladykin A.B. Fractures of the proximal shoulder - the ability to use pins // Margo Anterior - 2001 - No. 5-6.

2. Adedapo AO, Ikpeme JO. The results of internal fixation of three- and four-part proximal humeral fractures with the Polarus nail. Injury 2001.

3. Kazakos K, Lyras DN, Galanis V, et al. Internal fixation of proximal humerus fractures using the Polarus intramedullary nail. Arch Orthop Trauma Surg 2007; 127 (7): 503-8.

4. Mittlmeier TW, Stedtfeld HW, Ewert A, et al. Stabilization of proximal humeral fractures with an angular and sliding stable antegrade locking nail (Targon PH). J Bone Joint Surg Am 2003; 85 (Suppl 4): 136-46.

5. Resch H, Povacz P, Frohlich R, et al. Percutaneous fixation of three- and four-part fractures of the proximal humerus. J Bone Joint Surg Br 1997; 79 (2): 295-300.

6. Rockwood CA jr., Mansen FA, Wirth MA, Lippitt SB, Boshali KI The shoulder, 4 ^th edition, Saunders, an imprint of Elsevier Inc. Philadelphia, 2009.

7. Seidel H. Humeral fractures. Practice of intramedullary locked nails, Vol 1. 2002 Springer-Verlag, Heidelberg, Berlin, New York: 113-126.

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9. Jaberg H., Warner J., Jakob R. Percutaneous stabilization of unstable fractures of the humerus // J.B.J.S. - 1992. - Vol. 74-A. - P. 508-512.

Claims (1)

The method of reposition with closed intramedullary osteosynthesis of fractures of the proximal humerus, including minimally invasive transdeltoid access, entry into the subacromial space, dissection of the rotator cuff by a longitudinal two-centimeter incision from the edge of the large tubercle to the center of the head, matching the fragments and their fixation, which the awl is inserted into the head in the direction from the large tubercle to the center of the head and by turning the awl from top to bottom, eliminate the subluxation, lower a large tubercle and orient the head in the optimal position for nail insertion, in which it is temporarily fixed to the articular process of the scapula with two spokes, which are inserted through the small tubercle in front and through the large tubercle posterior to the canal, which is formed in the geometric center of the head of the humerus, after which compares the distal fragment with it and introduces the rod into the canal with fixation from the head, tubercles and diaphysis by blocking screws, after which the temporary spokes are removed.

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