RU2766814C1 - Method for reposition and fixation of bifocal fractures of proximal humerus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to traumatology and orthopedics, and can be used in surgical management of proximal humerus fractures. Greater tuberosity of humerus is mobilized; pulling the greater tuberosity with a wire distally and anteriorly and holding it in tension, the base of the tendon portion of the rotator cuff is sutured, covering the infraspinatus muscle in the center, and a portion of the supraspinatus and the small round muscles along the edges. Then the humeral head is advanced to the articular cavity of the scapula, and the diaphyseal portion of the fracture is brought under the humeral head; the position of the head and diaphysis fragments is fixed with K-wires. Cortical screw with a washer is installed in the diaphysis at the lateral edge of the tendon of the long head of the biceps; greater tuberosity is installed in place of its separation. Wire is fixed to the screw with tension. By twisting the screw with the washer, the wire is pressed to the bone; plate is applied and fixed with screws.

EFFECT: method provides neutralization of displacing forces of the wire tightening loop and interfragment compression, as well as restoration of blood supply to the shoulder head due to fixation of the wire loop to the anchor screw in combination with the locking plate.

1 cl, 5 dwg, 2 ex

Description

The invention relates to clinical medicine, in particular to traumatology and orthopedics, and can be used in the surgical treatment of fractures of the proximal humerus, namely fractures of the neck of the shoulder of types B and C in accordance with the universal classification AO/ASIF (M.E. Muller) recommended by AO Fund (1987).

Reposition and fixation of bifocal fractures of the proximal humerus is carried out by restoring the rotator cuff and creating interfragmentary compression using a wire tightening loop, contributing to an increase in the strength and reliability of fixing the plate to the patient's bone.

Analyzing the data of foreign and domestic literature on the surgical treatment of fractures of the surgical neck of the shoulder, it should be noted that the most common and effective methods of their treatment are open reposition, internal metal osteosynthesis. However, among the variety of described methods, there are no clear indications for the use of each of them, as well as an analysis of the long-term results of operated patients for each of the methods of operations (Novikov S.V., 2012).

A known method for external osteosynthesis of periarticular fractures of the proximal humerus (RF patent No. 2238054), made in the form of a plate of rectangular cross-section, containing the head part connected to the diaphyseal part through the transition part, and the head and diaphyseal parts are provided with through holes.

The disadvantage of this method is the low efficiency of the treatment of fractures of the humerus due to insufficiently tight fit of the device to the bone and the low resistance of the screws to pulling forces.

A known method for external osteosynthesis, containing a plate element of an arcuate cross section (RF patent No. 2238693), made with the possibility of fastening the head of the humerus, connected to each other by means of a slightly concave transitional part, and the head, transitional and diaphyseal parts are provided with through holes.

As disadvantages of the known device, one can indicate the low efficiency of treating humerus fractures due to the low resistance of the screws to pulling forces and the increased complexity of operation due to the use of screws of various sizes.

As a prototype adopted plate for small fragments of the head of the humerus (RF patent No. 2523652).

The disadvantage of the closest analogue is the low efficiency of treatment of fractures of the humerus due to insufficient reliability of fixation of fragments of the large and small tuberosity of the humerus.

This technique has a number of disadvantages, and the most significant of them is an attempt to pull fragments of displaced and partially fixed tubercles with a thread to the holes of the plate, which is tightly attached to the bone. Under these conditions, the sliding of the threads is difficult and the applied efforts are not always effective due to the loss of mobility of the bone fragments.

Faced with difficulties in repositioning and fixing comminuted fractures against the background of osteoporosis, a new approach to reposition and osteosynthesis of such fractures was developed.

The task to be solved by the proposed method is to develop a method that allows to increase the efficiency of reposition and fixation of bifocal fractures of the proximal humerus.

In order to reposition and fix bifocal fractures of the proximal humerus, a method was used to restore the rotator cuff and create interfragmentary compression using a wire tie loop and subsequent fixation of the fracture of the humeral neck with a spoon-shaped lockable plate.

The technical result is expressed in increasing the efficiency of fracture treatment by reducing the likelihood of osteosynthesis instability, secondary displacement (fragments) of the large tubercle, increasing the strength and reliability of fixing the plate to the patient's bone due to the following factors:

- reposition begins with the mobilization of the large tubercle, centering the head of the shoulder in the articular surface of the scapula, bringing the diaphysis under the head and further fixing the large tubercle with a wire loop to the “anchor” screw inserted in the cortical part of the distal fragment of the shoulder. With the tension of the wire, interfragmentary compression is created in the fracture zones of the large tubercle and the neck of the shoulder;

- the plate rests on the repaired parts of the head and additionally stabilizes the fracture with the help of lockable screws;

- there is an increase in the resistance of screws to pulling forces, an increase in the strength of osteosynthesis despite the thinning of the cortical as a result of osteoporosis.

The main goal of the operation is to restore the rotator cuff with elements of reposition and stable fixation, with the maximum possible preservation of the blood supply to the head of the shoulder. With intra-articular fractures, the blood supply to the head can be restored with early intervention and accurate reposition with compression elements. This is best done with a tie-wire loop placed behind the base of the rotator cuff tendons, attached to the greater tubercle, and fixed to the shaft of the humerus.

Compression in combination with a lockable plate creates conditions for the primary union of the fracture and, at the same time, contributes to the restoration of blood supply to the head of the shoulder due to newly formed intraosseous vessels.

The method is carried out as follows.

Access - from the acromioclavicular joint in the distal direction between M. pectoralis M. Deltoideus. Visualize the zone of fracture of the neck of the shoulder. As a rule, with bifocal fractures, the large tubercle is displaced proximally and posteriorly (Fig. 1). Moreover, the posterior displacement is more pronounced, since the total effect of the two muscles of the rotator cuff attached to it, infraspinatus and teres minor, exceeds the force of the supraspinatus muscle. After studying the nature of the fracture and detailing the location of the fragments, it is first necessary to mobilize the large tubercle. This is usually achieved with a single prong hook inserted behind the base of the rotator cuff tendon. When pulling the tubercle distally and anteriorly, it is necessary to make sure that it is sufficiently mobile, and the place of attachment of the rotator cuff is brought into the zone of visual inspection and is accessible for wire insertion. Holding the tension, the surgeon pierces the base of the tendon part of the rotator cuff with a needle turning into a wire (wire diameter - 0.7 mm), capturing the infraspinatus muscle in the center, and at the edges a part of the supraspinatus and small round muscles. Further, the large cusp is held by the tension of the wire loop and hence the hook can be removed.

In the second stage, the head of the shoulder is advanced to the glenoid cavity of the scapula, and the diaphyseal part of the fracture is brought under the head in the position of slight abduction. Thus, the head of the shoulder is even more pressed against the glenoid cavity of the scapula. This position of the fragments of the head and diaphysis is fixed with 1-2 Kirschner wires. Departing 1-1.5 cm from the fracture in the diaphysis at the lateral edge of the tendon of the long head of the biceps, a cortical 3.5 mm screw with a washer is installed. After the screw is inserted through both corticals, by pulling the wire loop, a large tubercle is set at the place of its separation, and the wire with an 8-shaped crossing is fixed to the previously inserted screw. In this case, the screw acts as an "anchor" device. The ends of the wire with tension are interconnected by twisting. For a more uniform tension, the opposite part of the wire loop is also tensioned by rotating the pre-formed small loop. The ends of the twisted wire and the loop are bent and pressed against the bone. The final element of this manipulation is screwing the screw with the washer until the wire is tightly pressed against the bone. If necessary, during the formation and fixation of the wire loop, a large tubercle can be additionally fixed to the head of the shoulder with a knitting needle. A similar manipulation can be performed with the tendon of the subscapularis muscle in the presence of a fracture and displacement of the lesser tubercle.

After making sure, according to the X-ray picture, that the reposition was correct, a spoon-shaped blocking plate is installed along the anteroexternal surface of the proximal shoulder and fixed in the diaphyseal part with a cortical (pressure) 3.5 mm screw, while the plate lies on the wire and partially on the large tubercle. Locking screws 3.5 mm are inserted sequentially into the proximal and distal parts of the plate. Holes coinciding with the course of the wire remain free of screws. Usually, it is 1-2, sometimes 3 holes. In this variant of osteosynthesis, the locking plate performs two functions: it stabilizes the achieved reposition and protects the compression created with the help of a tightening wire loop. A sufficient number of holes in the proximal end of the plate makes it possible to exclude 2–3 screws from the total number without loss of fixation (Fig. 2, 3).

Clinical examples of the implementation of the method.

Example 1. Patient E., 67 years old, was injured by falling on her left shoulder. Clinical and radiological examinations made it possible to establish the diagnosis of a closed fracture of the surgical neck of the left humerus with mixing, with a detachment of a large tubercle. Due to the inability to eliminate the displacement by conservative methods, and for the purpose of early activation after clinical examinations, surgical treatment was performed using the proposed method for repositioning and fixing bifocal fractures of the proximal humerus. After the surgical treatment in the hospital, an early rehabilitation course was started. The postoperative period proceeded without complications. On the control radiographs, the position of the fragments is satisfactory. Six weeks after surgery, there are x-ray signs of fracture consolidation (Fig. 4).

Example 2. Patient B., 65 years old, was injured by falling from a bicycle on her right shoulder. Clinical and X-ray examination made it possible to establish the diagnosis of "closed fracture of the surgical neck of the right humerus without displacement with separation of the large tubercle". On the control radiographs after 5 days, a secondary displacement was noted. For the purpose of early activation and elimination of displacement, surgical treatment was performed using the proposed method for repositioning and fixing bifocal fractures of the proximal humerus. An early course of rehabilitation was started. The postoperative period proceeded without complications. On the control x-rays, the position of the fragments is satisfactory. Five weeks after the operation, radiographs showed signs of fracture consolidation (Fig. 5).

References.

1. Zverev E.V., Degtyarev A.A., Shakola A.K. RU 2238054 C2 "Device for plate osteosynthesis of periarticular fractures of the proximal humerus". 2002.

2. Kostiv E.P., Tikhonova E.V., Kostiv R.E. EN 2523652 C1 Device for the treatment of fractures of the humerus. 2013.

3. Novikov S.V. Abstract of the dissertation for the degree of Cand. honey. Sciences. External compression-dynamic osteosynthesis of diaphyseal fractures of the femur, Moscow, 2012.

4. Guide to internal osteosynthesis. Method recommended by the AO group (Switzerland) / M.E. Muller [i dr.]. - M., 1996.

5. Universal classification of fractures (AO/ASIF).

BRIEF DESCRIPTION OF THE DRAWINGS

Fig. one.

In FIG. 1 shows a diagram of a bifocal fracture of the proximal humerus.

BRIEF DESCRIPTION OF THE DRAWINGS

Fig. 2.

In FIG. 2 shows compression osteosynthesis of a fracture of the proximal humerus with a wire tie loop.

BRIEF DESCRIPTION OF THE DRAWINGS

Fig. 3.

In FIG. 3 shows the final stage of osteosynthesis - additional fixation of the fracture with a lockable plate for the proximal shoulder.

BRIEF DESCRIPTION OF THE DRAWINGS

Fig. 4.

In FIG. 4 shows the control radiograph, the standing of the fragments is satisfactory, 6 weeks after surgery, there are signs of fracture consolidation.

BRIEF DESCRIPTION OF THE DRAWINGS

Fig. five.

In FIG. 5 shows the control x-rays, the standing of the fragments is satisfactory, 5 weeks after the operation, the radiographs show signs of fracture consolidation.

Claims (1)

A method for repositioning and fixing bifocal fractures of the proximal humerus, characterized in that the greater tuberosity of the humerus is mobilized; a large tubercle is pulled distally and anteriorly with a wire and, holding it in tension, the base of the tendon part of the rotator cuff is stitched, capturing the infraspinatus muscle in the center, and at the edges a part of the supraspinatus and small round muscles; then the head of the humerus is advanced to the glenoid cavity of the scapula, and the diaphyseal part of the fracture is brought under the head of the humerus, the position of the fragments of the head and diaphysis is fixed with Kirschner wires; in the diaphysis at the lateral edge of the tendon of the long head of the biceps, a cortical screw with a washer is installed; a large tubercle is installed at the place of its separation, the wire is fixed with tension to the screw; tightening the screw with a washer, press the wire to the bone; put on the plate and fix it with screws.

Images