RU2673146C1 - Method of osteosynthesis in the fracture of the proximal humerus - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to traumatology and orthopedics and may be applicable for osteosynthesis in case of fracture of the proximal humerus. Incision of the skin and subcutaneous fatty tissue 5–6 cm long is made between the anterior and middle deltoid muscle bundles from the anterolateral angle of the acromion to the projection of the axillary nerve. Deltoid muscle is spread. Individual strands of the supraspinatus are sewed, subscapular and subscapularis tendons with at least two stitches each, stitching the tendons of the supraspinatus and subscapular muscles at a distance of 1–1.5 cm from their attachment to the large tubercle of the humerus, and the tendon of the subscapularis muscle – at a distance of 1–1.5 cm from the place of its attachment to the small tubercle of the humerus. Reposition of fragments is carried out by traction over the ends of the threads passed through the tendons, while at the same time a large tubercle is repositioned by tractions in the lateral and distal directions beyond the ends of the threads through the supraspinatus and supine muscles. Then the head of the humerus is rotated by traction in the dorsal direction beyond the ends of the filament through the tendon of the subscapularis muscle. Keeping the thread behind, they perform a longitudinal incision with a length of 1–1.5 cm of the supraspinatus tendon, through which an inlet hole for the pin is formed in the head of the humerus. After insertion of the pin, it is fixed with the help of locking screws through the pin holes, the proximal locking screws being guided through the large and small tubercles of the humerus, and the distal locking screw through the diaphysis of the humerus. To the caps of the screws, they fix with a tension held through the tendons of the thread, while to the screws located in the region of the large tubercle of the humerus, fix the thread, held through the tendons of the supraspinatus and supine muscles, and the screw, held through the small tubercle of the humerus, fix the thread, held through the tendon of the subscapularis muscle.EFFECT: method allows to reduce the invasiveness and duration of the intervention, to increase the reliability of reposition, to prevent disruption of the blood supply to the humeral head.1 cl, 1 ex, 9 dwg

Description

The invention relates to medicine, namely to traumatology and orthopedics, and is used in surgical treatment of 2-, 3- and 4-fragmented fractures of the proximal humerus.

Intramedullary osteosynthesis with proximal humerus fracture pins is a minimally invasive method of implant insertion, which allows to reduce the volume of surgical intervention, maintain blood supply to the fragments and reduce the likelihood of developing aseptic necrosis. However, it must be borne in mind that a metal implant alone does not always provide sufficient stability of fragments, which requires, as a rule, additional fixation measures.

Performing reposition using surgical instruments or knitting needles can lead to destruction of bone fragments, a decrease in bone mass in the head of the humerus after insertion and subsequent removal, damage to the articular surface of the scapula or neurovascular structures during perforation of fragments with knitting needles, as well as to a violation of the blood supply to proximal fragments the humerus.

A known method of osteosynthesis of the proximal humerus with an intramedullary pin [Georgousis M., Kontogeorgakos V., Kourkouvelas S., Badras S., Georgaklis V., Badras L. Internal fixation of proximal humerus fractures with the Polarus intramedullary nail. Acta Orthop. Belg., 2010, 76, 4. 62-467], in which a 3 cm incision is made to insert the pin and closed reposition under the control of the electron-optical transducer by means of reduction, abduction and rotation of the upper limb. Next, osteosynthesis was performed with a pin and locked screws for 2 and 3-fragment fractures. With 4 fragmentary fractures, the incision was widened, the axillary nerve was visualized, and fragments were openly repositioned.

However, this method has several drawbacks: closed reposition at 2 and 3 fragmentary fractures does not always ensure the reliability of osteosynthesis, it is impossible to achieve accurate reposition only using manipulations with the upper limb without auxiliary tools, and expanded access at 4 fragmentary fractures with visualization of the axillary nerve and open reposition of fragments is traumatic. The lack of additional fixation of rotator tendons does not allow to begin early movements in the shoulder joint in the postoperative period.

A known method of reposition of fragments with closed intramedullary osteosynthesis of fractures of the neck of the humerus [RU 2513594, C1], where through a minimally invasive transdeltoid access is the entrance to the subacromial space and dissection of the rotator cuff by a longitudinal two-centimeter incision. The 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, the subluxation is removed, the large tubercle is brought down and the head is oriented to the optimal position for nail insertion, in which it is temporarily fixed to the articular process of the scapula with two knitting needles, which are inserted through small tubercle in front and across large tubercle. After that, the distal fragment is compared with it and the rod is inserted into the canal with fixation of the head, tubercles and diaphysis by blocking screws. Then the temporary spokes are removed.

However, this technique cannot be applied for 4-fragment fractures due to the impossibility of performing a closed reposition. Holding spokes into the articular surface of the scapula inevitably damages cartilage and can lead to the development of early post-traumatic arthrosis. Reposition with the help of an awl and knitting needles leads to loss of bone mass of the head of the humerus, may be accompanied by damage to soft tissues, blood vessels and nerves in this area.

The closest in technical essence and functional result is the method of osteosynthesis of the proximal shoulder, which we took as a prototype [Stedtfeld H.-W., Mittlmeier T. Fixation of Proximal Humeral Fractures with an Intramedullary Nail: Tipps and Tricks // Eur J Trauma Emerg Surg 2007 No. 4. p. 367-374.].

By this technique, anterolateral access is performed. The fracture site is exposed and non-absorbable sutures of one stitch are sewn into the tendons of the supraspinatus, infraspinatus and subscapularis muscle. The initial (intermediate) reposition of the fracture is carried out using these threads by traction for them. Then follows the continuation of the reposition with the help of a possible additional impact of the elevators or hooks on the fragments. The final reposition and fixation is further performed by knitting needles. Only after this is osteosynthesis of the proximal humerus performed by an intramedullary pin. Further fixation of the tendons of the rotator muscles to the specialized holes in the screw caps is considered as additional. Why re-flashing tendons and fixing the threads to the screws is required. In this case, the fixation of the threads is carried out in special holes of the screws.

The disadvantages of the prototype method can be considered the need to use surgical instruments for reposition, complication of the intervention, since the stitches sewn at the beginning of the thread cannot be used in the future, and for the final fixation of the threads, repeated tendon suturing is required. Sutures sewn with one stitch through the tendon can slip during traction, which does not allow for reliable reposition and involves the use of additional reposition techniques. The need to conduct the thread through special holes to increase the reliability of fixation of fragments complicates the intervention, requires special screws with holes for fixing the threads.

The technical problem lies in the development of a less traumatic method for the surgical treatment of proximal humerus fractures, including three- and four-fragment fractures, by intramedullary osteosynthesis, which provides adequate semi-open reposition of fragments and their reliable fixation.

The technical result achieved by the invention is

- reducing the morbidity and duration of intervention during intramedullary osteosynthesis of two-, three- and four-fragmented fractures of the proximal humerus due to the use of low-traumatic semi-open access and comparison of fragments of the humerus; reducing the amount of surgical instruments used, the use of the same technique - flashing of rotator muscles both at the stage of reposition and at the stage of fixation of fragments;

- improving the reliability of the reposition while simplifying it by eliminating the use of additional metal devices by increasing the volume of manipulation of the position of the fragments by using the shoulder rotator muscles as a result of using original stitching techniques;

- prevention of complications caused by a decrease in bone mass, impaired blood supply to the head of the humerus, damage to soft tissues, blood vessels and nerves, articular cartilage in the area of surgical intervention by eliminating the use of knitting needles for reposition and fixation;

- improving the stability of osteosynthesis with its simplification, ease of implementation, prevention of secondary displacement of fragments due to additional soft-tissue stabilization of rotator tendons on screw caps carried through a pin.

Thus, the proposed method has the following advantages. It allows you to:

1. to reduce the morbidity and duration of the osteosynthesis of a fracture of the proximal humerus by reducing the number of surgical instruments used;

2. improve the accuracy of reposition due to semi-open surgical access and fixation of key fragments of the proximal humerus;

3. manipulation of the threads allows to repair large and small tubercles with minimal trauma and high accuracy, eliminate subluxation, visualize and form the correct entry point of the intramedullary pin;

4. additional soft-tissue stabilization of rotator tendons on the screw caps increases the stability of osteosynthesis, neutralizes the muscle strength of rotators and prevents the possible secondary displacement of fragments after osteosynthesis;

5. soft tissue reposition of the fracture due to threads, rather than metal devices, allows maintaining bone mass and blood supply to the head of the humerus, preventing damage to the articular surface of the scapula or neurovascular structures with possible perforation of fragments with knitting needles.

The invention consists in the following.

Osteosynthesis in a fracture of the proximal humerus includes reposition of fragments, intramedullary insertion of a pin, and fixation of the latter to the humerus with blocking screws. In this case, an incision is made in the skin and subcutaneous fatty tissue 5-6 cm long between the anterior and middle bundles of the deltoid muscle from the anterolateral angle of the acromion to the projection of the axillary nerve. The deltoid muscle is bred. Then, the supraspinatus, infraspinatus, and subscapularis muscle are sutured with separate tendon threads with at least two stitches each. Moreover, the tendon of the supraspinatus muscle is sutured at a distance of 1-1.5 cm from the point of attachment to the large tubercle of the humerus, the tendon of the infraspinatus muscle is sutured at a distance of 1-1.5 cm from the point of attachment to the large tubercle of the humerus. The tendon of the subscapularis muscle is sutured at a distance of 1-1.5 cm from the point of attachment to the small tubercle of the humerus. Reposition of fragments is carried out by traction at the ends of the threads drawn through the tendons. First, reposition of the large tubercle is carried out by traction in the lateral and distal directions beyond the ends of the threads drawn through the tendons of the supraspinatus and infraspinatus muscles. Then rotate the head of the humerus by traction in the dorsal direction beyond the ends of the thread held through the tendon of the subscapularis muscle. The reposition is limited by the said traction, without using other methods for repositioning, including using additional exposure to elevators or hooks on fragments of the humerus. While retaining traction for the threads, a longitudinal incision is made with a length of 1-1.5 cm of the tendon of the supraspinatus muscle. Through this incision, an inlet for the pin is formed in the head of the humerus. After the insertion of the pin, it is fixed using locking screws through the holes of the pin. Moreover, the proximal locking screws pass through the large and small tubercles of the humerus, and the distal locking screw through the diaphysis of the humerus. Threads are fixed to the screw caps with tension. At the same time, the threads held through the tendons of the supraspinatus and infraspinatus are fixed to the screws located in the region of the large tubercle of the humerus. To the screw held through the small tubercle of the humerus, fix the threads held through the tendon of the subscapularis muscle. The fixation of the ends of each thread is made after its eight-shaped intersection.

The method is illustrated by the following figures.

In FIG. 1 shows anterolateral surgical approach, lateral view.

In FIG. 2 shows the stage of flashing tendons of rotators with threads, view from the lateral side.

In FIG. 3. The stage of reposition of fragments by traction behind the threads (front view) is presented.

In FIG. 4. shows an x-ray (direct projection) of the right humerus: the stage of insertion of the pin (while maintaining traction behind the threads).

In FIG. Figure 5 presents a radiograph (direct projection) of the right shoulder joint of patient L. upon admission to the hospital.

In FIG. 6 shows a radiograph (side view) of the right shoulder joint of patient L. upon admission to the hospital.

In FIG. Figure 7 presents a radiograph (direct projection) of the right shoulder joint of patient L. after osteosynthesis is completed (reposition and fixation of fragments of the head and diaphysis with screws is shown).

In FIG. Figure 8 shows a radiograph (lateral projection) of the right shoulder joint of patient L. after completion of osteosynthesis (reposition and fixation of fragments of the head and diaphysis with screws).

In FIG. 9 shows the final stage of the operation after fixing the threads on the screw caps (view from the lateral side).

The proposed method of semi-open intramedullary osteosynthesis of fractures of the proximal part 1 of the humerus is as follows. Anterolateral access 2 is made between the anterior and middle bundles of the deltoid muscle. A linear incision is made 5-6 cm from the anterolateral angle of the acromion 3 parallel to the direction of the fibers of the deltoid muscle, not reaching the projection of the axillary nerve 4. After dilution of the deltoid muscle, the tendon of the long head of the biceps 5 is visualized, flashing with two stitches of the supraspinatus tendon 6, the infraspinatus 7 muscles at a distance 1-1.5 cm from the point of attachment to the large tubercle of the humerus and subscapularis muscle 8 at a distance of 1-1.5 cm from the point of attachment to the small tubercle of the humerus.

Using traction for these threads 9, it is possible to manipulate the fragments and reposition them under the control of the image intensifier. Initially, traction is performed in the lateral and distal directions for the tendons of the supraspinatus and infraspinatus muscle to reposition the large tubercle.

The rotation of the head along the axis of the humerus is corrected by traction in the dorsal direction for the tendon of the subscapularis muscle. Keeping traction for the threads and rotating the head of the humerus 10 (depending on the varus or valgus displacement) in the desired direction, an incision is made 1-1.5 cm long longitudinally to the tendon fibers of the supraspinatus muscle. Through this incision at the most proximal point of the head of the humerus (at the top of the humerus) with an awl, an inlet for the pin 11 is formed. After the pin is inserted using the guide 12 into the bone marrow canal, the “automatic” reposition of the humeral diaphysis 13 occurs.

Next, under the control of the image intensifier, the large 14 and small tubercles 15 are fixed with proximal locking screws 16. The aforementioned threads are fixed to the screw caps protruding above the surface of the tubercles after an 8-shaped intersection, which enhances the reliability of osteosynthesis and prevents secondary displacement in the future. Clinical example.

Patient L., 79 years old. Household injury - fell at home on the area of the right shoulder. Delivered by an ambulance to the hospital with a diagnosis of Closed fracture of the surgical neck and large tubercle of the right humerus with displacement of fragments. Radiographs at admission (Fig. 5-6). On the 3rd day, the patient underwent surgery: half-open reposition of fragments according to the proposed method, intramedullary osteosynthesis of the proximal section with a rod with blocking (Fig. 7-8). All radiographs of the shoulder joint were necessarily performed in two projections.

On control radiographs after 6 weeks from the moment of surgery, consolidation of a fracture of the right humerus was achieved. On examination, after 18 weeks from the moment of the operation, the function of the right shoulder joint was restored, the range of movements was complete, and there was no pain syndrome.

The proposed method operated on 39 patients. The treatment results are rated as good and excellent.

Claims (1)

A method of osteosynthesis in a fracture of the proximal humerus, including reposition of fragments, osteosynthesis by intramedullary insertion of a pin and fixing the latter to the humerus with blocking screws, characterized in that an incision of the skin and subcutaneous adipose tissue 5-6 cm long between the anterior and middle deltoid bundles muscles from the anterolateral angle of the acromion to the projection of the axillary nerve, breed the deltoid muscle; stitch with separate strands of the tendon of the supraspinatus, infraspinatus and subscapularis muscles with at least two stitches each, and the tendons of the supraspinatus and infraspinatus muscles are stitched at a distance of 1-1.5 cm from the places of their attachment to the large tubercle of the humerus, and the tendon of the subscapularis muscle is sewn onto a distance of 1-1.5 cm from the place of its attachment to the small tubercle of the humerus; reposition of fragments is carried out by traction at the ends of the filaments drawn through the tendons, while first reposition of the large tubercle by traction in the lateral and distal directions behind the ends of the filaments, carried out through the tendons of the supraspinatus and infraspinatus muscles, then the humeral head is rotated by traction in the dorsal direction beyond the ends suture through the tendon of the subscapularis muscle; while retaining traction by the threads, a longitudinal section is made of a length of 1-1.5 cm of the tendon of the supraspinatus muscle, through which an input hole for the pin is formed in the head of the humerus, after the insertion of the pin, it is fixed with blocking screws through the holes of the pin, with proximal blocking screws pass through the large and small tubercles of the humerus, and the distal blocking screw through the diaphysis of the humerus; threads are fixed to the screw caps with tension drawn through the tendons of the thread, while to the screws located in the region of the large tubercle of the humerus, the threads passed through the tendons of the supraspinatus and infraspinatus muscles, and to the screw held through the small tubercle of the humerus, the threads held are held through the tendon of the subscapularis muscle, while the fixation of the ends of each thread is made after its eight-shaped intersection.

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