RU2810272C1 - Method of sequential minimally invasive osteosynthesis of humerus in the lower third with plate for gunshot fractures - Google Patents

Abstract

FIELD: medicine; traumatology; orthopedics.

SUBSTANCE: invention can be used for osteosynthesis of the humerus in the lower third with a plate for gunshot fractures. A proximal approach is made through the triceps brachii muscle to the posterior surface of the middle third of the shoulder, 8 cm long. The radial nerve passing in the spiral canal of the humerus is mobilized. Access is made in the lower third of the humerus along the posterior outer edge of the shoulder to the 5 cm long external condyle. The plate is inserted through the distal access under the triceps muscle. It is passed epiperiosteally over the fracture site and the proximal end of the plate is brought out into the wound, while the plate should be between the humerus and the radial nerve. The distal edge is placed along the posterior surface on the external condyle, and the proximal edge is placed along the posterior surface of the upper third of the diaphysis of the humerus. The final reposition of the humerus is performed under the control of an electron-optical converter and the plate is fixed in the proximal and distal fragments with at least three screws with angular stability each.

EFFECT: method provides effective and safe fixation of bone fragments in gunshot fractures of the diaphysis of the humerus in the lower third, and, as a consequence, restoration of its anatomy due to visualization and mobilization of the radial nerve in the spiral canal of the humerus.

1 cl, 4 dwg, 1 ex

Description

The invention relates to the field of medicine, namely to traumatology and orthopedics, and is intended for surgical treatment of wounded people with gunshot fractures of the diaphysis of the humerus in the lower third.

It is known that in local armed conflicts with gunshot fractures of the bones of the extremities, the humerus is damaged quite often and accounts for 22.3% of cases. At the moment, according to many domestic and foreign scientists, the most optimal treatment option for gunshot fractures is sequential osteosynthesis, namely, primary fixation of bones using the method of external osteosynthesis (until the condition of the wounded, blood counts, and wound healing improve) followed by transition to internal fixation . The use of internal fixators makes it possible to most effectively restore the function of the injured limb. The safest for the patient, from the point of view of possible infectious complications, is minimally invasive osteosynthesis. This technique involves implanting a wounded internal fixator into the damaged segment through small incisions that do not communicate directly with the gunshot fracture area.

In the modern scientific literature, we have not found information about the minimally invasive technique of internal osteosynthesis used for fractures of the humerus in the lower third.

There is a known method of fixing fragments of the diaphysis of the humerus with a pin-rod device, proposed at the Department of Military Traumatology and Orthopedics of the Military Medical Academy (Khominets V.V. Treatment of wounded limbs in wars and armed conflicts: monograph / V.V. Khominets, V.M. Shapovalov, S.V. Mikhailov, L.K. Brizhan. - St. Petersburg: historical illustration, 2021. P. 138-144).

The disadvantages of using this method are the risk of damage to blood vessels and nerves, local (“wire”) osteomyelitis, secondary displacement of fragments, fracture of the rod or wire, skin necrosis from pressure from parts of the device, contact dermatitis, persistent joint contractures. According to the scientific literature, the incidence of pseudarthrosis of the humerus during treatment with external fixation devices is 7-13%, fusion with deformation 11-18%, delayed consolidation 14-27%.

There is also a known method of traditional external osteosynthesis of the humerus through the posterior approach (Thomas P. Rudy, Richard E. Buckley, Christopher G. Moran AO - Principles of treatment of fractures. Second revised and expanded edition. Translation into Russian by Alexander A. Sitnik. Volume 2 - private traumatology, 2013. pp. 595-608). This type of osteosynthesis is performed only after early compensation or subcompensation of the main life-supporting systems during the development of a traumatic disease in victims with severe injuries accompanied by shock, and correction of blood loss, uncomplicated healing of wounds (defects) of the integumentary tissue, absence of inflammatory changes in wounds and tissues around the elements of the external fixation apparatus , as well as systemic signs of inflammation.

However, the disadvantages of using the above method are the wide exposure of the area of the gunshot fracture of the humerus through compromised soft tissue for open reduction and internal fixation. This, in turn, can lead to impaired blood supply and, as a result, an increased risk of nonunion and infectious complications.

The purpose of the invention is to create an effective and safe method for fixing bone fragments in gunshot fractures of the diaphysis of the humerus in the lower third.

This goal is achieved through minimally invasive, sequential osteosynthesis of the humerus. For this, the patient is placed on his side, the arm is placed on a softened cushion with a diameter of about 4 cm with the ability to flex the forearm up to 120°. Proximal access is performed through the triceps brachii muscle to the posterior surface of the middle third of the shoulder, 8 cm long; In this case, it is necessary to revise and mobilize the radial nerve passing in the spiral canal of the humerus. Then access is made in the lower third of the humerus along the posterior outer edge of the shoulder to the external condyle 5 cm long; then we introduce the plate through the distal access under the triceps muscle; We carry it epiperiosteally over the fracture site and bring the proximal end of the plate into the wound. It is important that the plate is located between the humerus and the radial nerve (the nerve above the plate). The distal edge of the plate is placed along the posterior surface on the lateral condyle, and the proximal edge - along the posterior surface of the upper third of the diaphysis of the humerus; after which the final reposition of the humerus is performed under the control of an electron-optical converter and the plate is fixed in the proximal and distal fragments with at least 3 screws with angular stability each.

The use of this method of fixation of fragments of the humerus allows for its reliable and stable stabilization without restricting mobility in the adjacent joints, which improves the treatment outcome.

The invention is illustrated by the following figures.

Fig. 1. Radiographs of the left shoulder, which reveals a comminuted fracture of the humerus in the lower third with displacement of fragments. The left humerus is fixed with an external apparatus from the military field rod kit (KSVP) on 4 rods.

Fig. 2. Surgical approaches to the humerus are presented: proximal, the radial nerve is visualized. (2) and distal (3). The edges of the proximal wound are separated by a retractor (1).

Fig. 3. A plate with angular stability of screws on the posterior aspect of the humerus through minimally invasive approaches is shown (4).

Fig. 4. X-ray of the left shoulder on the 1st day after surgery, on which the humerus is fixed with a plate with angular stability of screws, while the proximal fragment is fixed with 3 screws, and the distal fragment with 5 screws. The proximal end of the plate is adjacent to the posterior surface of the upper third of the diaphysis, the distal end is adjacent to the posterior surface of the lateral condyle of the humerus.

In fig. 2 the following notations are adopted:

1 - retractor installed in the proximal wound;

2 - proximal access to the humerus along the posterior surface;

3 - postero-external access to the humerus in the lower third. In fig. 3 the following notations are adopted:

4 - a plate with angular stability of screws was installed along the posterior surface of the humerus through minimally invasive approaches.

The method is carried out as follows.

The method of sequential minimally invasive osteosynthesis of the humerus in the lower third with a plate for gunshot fractures is performed in several successive stages. The patient is positioned on the healthy side, the injured upper limb is placed on an attachment or bolster, and the forearm is placed in a mid-position between supination and pronation. The first step is to perform proximal access through the triceps brachii muscle 2, 8 cm long, to the posterior surface of the middle third of the humerus (Fig. 2). At the same time, during the access process, we perform visualization and mobilization of the radial nerve from the spiral canal, and, if necessary, neurolysis. In the second stage, we perform access to the lower third of the humerus along the postero-outer edge of the shoulder and 1.5-2 cm proximal to the external condyle 3, 5 cm long (Fig. 2). We dissect the triceps brachii muscle along the muscle fibers to the lateral condyle of the humerus. The next step is to introduce a plate with angular stability of the screws in the formed axillary tunnel, sliding along the posterior surface of the humerus (Fig. 3). In this case, the drill guide for angularly stable screws is inserted into one of the holes and used as a handle. Then the assistant, under the control of the image intensifier, performs a closed reposition of the bone fragments of the humerus, and the surgeon, at the same time, carefully continues to insert the plate epiperiosteally, passing from bottom to top above the fracture zone. Through the distal approach on the shoulder, the distal edge of the plate is placed along the posterior surface of the lateral condyle. Next, the proximal end of the plate is temporarily fixed to the diaphysis of the humerus using a Kirschner wire. Under the control of the image intensifier, we finally perform a closed reduction of the bone fragments of the humerus (axis, length and rotation) and fix the distal end of the plate, correctly oriented on the lateral condyle of the humerus, with screws. We fix the proximal end of the plate to the humerus with screws with angular stability (Fig. 4). We install drainage in the area of surgical access. We suture the surgical wounds layer by layer.

An example of the practical use of the method.

Wounded R., 32 years old, received a gunshot shrapnel penetrating wound of the left shoulder with a gunshot comminuted fracture of the humerus in the lower third with displacement of fragments.

At one of the stages of medical evacuation, the victim underwent surgery: primary surgical treatment of wounds of the left shoulder, fixation of the left shoulder with the KSVP device (Fig. 1 A, B). 2 days after the injury, the patient was taken to the Military Traumatology and Orthopedics Clinic of the Military Medical Academy. The examination revealed a gunshot fragmentation through wound of the left shoulder with a gunshot comminuted fracture of the humerus in the lower third with displacement of fragments (Fig. 1 A, B). At the clinic, the wounded man was dressed daily with levomekol ointment to bandage the wounds of his right shoulder and received complex conservative treatment, namely: broad-spectrum antibacterial therapy and analgesics. The victim underwent primary delayed suturing of the wounds of the left shoulder on the 6th day after admission. On the 18th day after admission to the clinic, healing of the gunshot wounds of the soft tissue of the left shoulder was noted. 3 weeks after the injury, an operation was performed: dismantling of the CVS device, closed reduction, minimally invasive osteosynthesis of the left humerus with a plate with angular stability of screws (Fig. 3, 4). In the postoperative period, the operated limb was immobilized with a scarf bandage for three weeks. Active movements in the shoulder and elbow joints began on the second or third day after the operation until the pain subsided.

Four patients were operated on using the developed technique. All received satisfactory anatomical and functional results.

Claims (1)

A method of minimally invasive osteosynthesis of the humerus in the lower third with a plate for gunshot fractures, characterized in that proximal access is performed through the triceps brachii muscle to the posterior surface of the middle third of the shoulder, 8 cm long, while mobilizing the radial nerve passing in the spiral canal of the humerus; then access is made in the lower third of the humerus along the postero-outer edge of the shoulder to the external condyle 5 cm long; then the plate is inserted through the distal access under the triceps muscle; they carry it epiperiosteally over the fracture site and bring the proximal end of the plate into the wound, while the plate should be between the humerus and the radial nerve, install its distal edge along the posterior surface on the lateral condyle, and the proximal edge along the posterior surface of the upper third of the diaphysis of the humerus; after which the final reposition of the humerus is performed under the control of an electron-optical converter and the plate is fixed in the proximal and distal fragments with at least three screws with angular stability each.