RU2823734C1 - Method of treating multi-fragmentary femoral fractures in children - Google Patents

Abstract

FIELD: medicine; traumatology; orthopedics.

SUBSTANCE: invention can be used in treating multi-fragmentary femoral fractures in children. Biomechanical axis of extremity, its length is restored, and rotational displacement is eliminated by aligning the line conditionally drawn through the anterior superior iliac spine, the middle of the patella and the first interdigital space. Length shift is eliminated. Control X-ray imaging is performed and position of fragments and fragments is determined with subsequent installation of marks in the form of injection needles. Distal and proximal base rods are inserted along the outer-lateral surface of the thigh into the distal and proximal bone fragments, on which the distal and proximal base supports are installed, and between them by means of threaded rods, reposition supports are installed. Fragments are repositioned by introducing into each rectangular intermediate fragment two pins with thrust sites perpendicular to the displacement plane, parallel to each other, with maximum spacing of points of their introduction, placing the support pins on the fragment on the side of the displaced cortical layer opposite each other. At the pushing pin, the sharpened part is cut off at an acute angle at distance of 2 cm from the thrust platform, and at the pulling pin—a blunt end to the base of the thrust platform. Further, the fragments are repositioned by passing the wire with a thrust platform through the base of the splinter—a cortical layer, through the center of the splinter, at angle of 90° to the base so that to create counter-lateral compression between the fragment and its bed. After the counter-lateral compression, the pins are fixed on the external brackets of the apparatus.

EFFECT: method enables reducing injuries and improving the functional outcome of treating multi-fragmentary fractures of the femur in children due to single-step elimination of displacement along length and rotational displacement, as well as restoration of biomechanical axis of extremity.

1 cl, 6 dwg, 1 ex

Description

The invention relates to medicine, namely traumatology, and can be used in the treatment of multi-comminuted fractures of the femur.

Treatment of multi-comminuted fractures of the femur remains one of the urgent problems of traumatology and orthopedics, which is due not only to the tendency to increase high-energy injuries in the general structure of injuries in recent years and the susceptibility of the young and most socially active contingent of the population, including children and adolescents, to them, but also to the high frequency of complications. In addition, the presence of bone fragments of various shapes, sizes and quantities often make the use of traditional (external and intramedullary) osteosynthesis unacceptable in children due to high trauma and technical complexity. It should be noted that the term "fragment" is used in medical literature to denote small fragments of bone tissue, often triangular in shape, and the term "fracture" is usually used to denote larger bone fragments, most often rectangular or similar in shape, an intermediate bone fragment.

There are numerous known methods for treating comminuted and multi-comminuted fractures of the femur, including the installation of an intramedullary rod and means for blocking it in the bone [1,2]. However, the use of intramedullary structures is traumatic, numerous difficulties arise during the installation of rods, they cause synostosis of growth zones, since they are carried out with their damage, which is unacceptable in pediatric patients. In addition, the extreme diversity in the number and shape of fragments in multi-comminuted fractures makes intramedullary osteosynthesis technically impossible in the treatment of this type of fracture. The negative facts against the use of this type of surgical treatment is the development of fat embolism after the use of intramedullary osteosynthesis.

The use of bone plates is also unacceptable in pediatric patients, since multi-fragmentary fractures require long incisions with longitudinal skeletonization (periosteum detachment in the area of plate installation) and periosteum detachment along the entire fracture, which is negative due to the traumatic nature of the operation, as well as the disruption of the blood supply to bone fragments and the consolidation process.

In children, self-correction of deformations that arise from improperly fused fractures of long tubular bones is possible before the growth zones close. The intensity of self-correction is determined by the patient's age and the localization of the residual deformation. In adolescents, a displacement within 15-20° does not require ideal repositioning and is leveled out with growth on its own. Therefore, when repositioning comminuted fractures of long tubular bones, it is necessary to restore the biomechanical axis of the limb, its length with the elimination of rotational displacement with moderate elimination of angular displacement, and displacement in width, with residual (15-20°) displacement [3].

Therefore, with this type of injury in children, it is inappropriate to use extramedullary and intramedullary types of osteosynthesis, as traumatic methods of osteosynthesis and technically unsuitable, and the most justified is the use of external fixation devices, even if the designs of the devices used do not meet the requirements of ideal reposition.

Thus, in order to reduce the trauma of surgical intervention, reduce the time it takes to perform, and also to optimize the process of consolidation of fragments and fragments of the femur, the choice of tactics and method of treatment of pediatric patients with comminuted fractures of the femur remains the use of transosseous osteosynthesis with external fixation devices.

A device for treating comminuted fractures of the femur in children is known [4], taken by us as a prototype, containing distal and proximal supports, each of which is made in the form of an arcuate plate with through slits. Reposition of the bone fragment is performed due to the intermediate repositioning support, which is fixed opposite the intermediate bone fragment. Depending on the location of the intermediate fragment, outside or inside, from the central fragments of the femur, which are in the already repositioned position, a pin with a stop pad is inserted into the center of this fragment. With an external location of the intermediate bone fragment, to create counter-lateral compression, a pin with a stop pad, installed in the specifier, is carried out from outside to outside, pushing the pin stop, thereby creating counter compression between the fragment and its bed.

In the case of the location of the intermediate bone fragment inward, relative to the central fragments of the femur, a spoke with a stop pad is passed through the center of the intermediate bone fragment from the inside to the outside, and its sharpened end is mounted on a spoke fixator, and compression is performed.

However, this device provides for the reposition and fixation of comminuted fractures with one intermediate fragment, and is not intended for the treatment of patients with multi-comminuted fractures of the femur. This is explained by the fact that intermediate fragments and fragments can vary in shape and length. In the presence of a long fragment of a segment, its reposition on one spoke with a thrust pad is impossible.

The essence of the proposed invention lies in a set of essential features sufficient to achieve the desired technical result, consisting in the creation of a method that provides for a reduction in the trauma of the intervention and the time of its implementation, when performing reposition of a multi-comminuted fracture, and fixation, with the exclusion of secondary displacement, with the simultaneous implementation of longitudinal and lateral compression.

The essence of the method for treating multi-fragmentary fractures of the femur with a rod apparatus in children includes the introduction of 2 intraosseous rods into the proximal and distal fragments, mounting proximal and distal supports on them in the form of curved plates, connecting the supports with threaded rods located parallel to the direction of the bone fragments, installing bone rods in remote rod fixators secured to the said supports, and fixing an intermediate repositioning support on the threaded rods. Reposition of multi-fragmentary fractures of long tubular bones begins with the restoration of the biomechanical axis of the limb, its length, and the elimination of rotational displacement by aligning a line conditionally drawn through the anterior superior iliac spine, the middle of the patella, and the first interdigital space. Simultaneously, the length displacement is eliminated, and the value of the required elongation is determined as the difference in the length measurements of the healthy and damaged limbs, along lines drawn from the anterior superior iliac spine - the upper point, to a point 1 cm above the upper pole of the patella - the lower point. Control radiography is performed to monitor the completed reposition, determine the levels, sizes, and positions of intermediate fragments and fragments, and install "markers" in the form of injection needles. Distal and proximal base rods are inserted along the outer lateral surface of the thigh into the distal and proximal bone fragments, on which distal and proximal base supports are installed. Between them, using threaded rods, reposition supports are installed, depending on the number of fragments. Remote brackets are mounted on these supports, on which pin fixators are installed to secure pins with stop pads. The basic supports are connected to the intraosseous rods using pin fixators and standard remote brackets. To perform reposition of the fragments, two pins with stop pads are inserted into each rectangular intermediate fragment perpendicular to the plane of displacement, parallel to each other, with the maximum spacing of the insertion points, placing the stop pads of the pins on the fragment from the side of the displaced cortical layer, opposite each other. In this case, the pins are bitten off, depending on their purpose and the position of the fragment: the sharpened part of the "pushing" pin is bitten off at an acute angle at a distance of 2 cm from the stop pad, and the blunt end of the pulling pin is bitten off to the base of the stop pad. To reposition the fragments, a pin with a thrust pad is inserted through the base - the cortical layer of the fragment, through its center, at an angle of 90° to the base so as to create counter-lateral compression between the fragment and its bed: when the base of a triangular fragment is located on the side of the outer surface of the injured segment, the pin with a thrust pad is inserted from the outside to the inside, and when the base of a triangular fragment is located on the side of the inner surface of the injured segment, the pin with a thrust pad is inserted from the inside to the outside. After performing counter-lateral compression, the pins are secured to the external brackets of the device.

When the fragment is positioned at an angle to the axis of the limb segment, to insert a pin with a stop pad perpendicular to the plane of fragment displacement, the technique of "gathering" soft tissues is used, that is, the skin with soft tissues is manually pulled together from the side of the insertion of the repositioning pin, in the direction of this pin. The displacement of the fragment in the lateral projection is eliminated by moving it, with simultaneous manual traction of the pins with stops upward or downward.

Reposition of multi-comminuted fractures of long tubular bones begins with restoration of the biomechanical axis of the limb, since deviations of its points from the line, conditionally drawn through the anterior superior iliac spine, the middle of the patella, and the first interdigital space, are important for consolidation of bone fragments. Failure to comply with this rule leads to delayed consolidation of fragments, or to the formation of a false joint.

When eliminating the displacement along the length, a displacement of 1 cm above the upper pole of the patella is performed to prevent damage to the distal growth zone; neglect of this action, as the patient grows, leads to shortening of the limb segment.

Control radiography to monitor the completed reposition, determine the size and position of intermediate fragments and fragments, and apply “marks” in the form of injection needles, is performed in order to determine the level and direction of insertion of pins with stop pads to perform their reposition.

The need to mount the device with the elimination of angular displacement and displacement across the width of fragments and fragments is explained by the fact that in case of multi-fragmentary fractures of long tubular bones with a different number of fragments and fragments of various shapes (wedge-shaped, triangular, rectangular, etc.), it is not always possible to perform reposition ideally, close to the anatomical norm of the shape of a long tubular bone, or it takes a long period of time, which increases both the trauma of the intervention and the anesthesia time, which is not always justified and possible due to the general condition of the patient. With a large number of fragments and fragments of a long tubular bone, the arrangement of the device is cumbersome and heavy, since it requires additional units and devices, which will not allow for a dosed load on the limb from the 4th day after surgery. Providing a dosed load on the limb in the early postoperative period is of fundamental importance for the consolidation process, and was introduced by G.A. Ilizarov in the register of "DISCOVERIES" [5].

Reposition of fragments and fragments in multi-comminuted fractures consists of bringing these fragments and fragments closer and adapting them to their bed. In case of technical difficulties, residual displacement (deformation) of up to 15-20° is allowed, since in children, before the growth zones close, self-correction of deformations that arise from improperly fused fractures of long tubular bones is possible. The intensity of self-correction is determined by the patient's age and the localization of the residual deformation. At the age of 13-15 years, when this type of injury is most common, self-correction of the angle of residual displacement (deformation) by 15-20° was observed with growth [3]. Adaptation of fragments and fragments is achieved by using pins with stop pads that ensure the movement of fragments and fragments, creating counter-lateral compression between the fragment or fragment and its bed.

The introduction of two pins with support pads into each fragment, perpendicular to the plane of displacement, parallel to each other, with the maximum spacing of the points of their introduction, placing the support pads of the pins opposite each other, on the side of the displaced outer or inner cortical layer of the fragment, ensures its repositioning in direct and lateral projection.

Biting off the sharpened part of the “pushing” spoke at an acute angle, at a distance of 2 cm from the stop platform, ensures the introduction of the end of this spoke into the bone fragment and its control.

Biting off the blunt end of the "pulling" needle to the base of the stop platform ensures the absence of additional trauma to soft tissues during movements of the limb segment. The use of the "gathering" technique of soft tissues (Fig. 4), when inserting a needle with a stop platform perpendicular to the plane of fragment displacement, with the fragment positioned at an angle to the axis of the limb segment, allows avoiding additional trauma from the cutting of soft tissues by the needle.

The displacement of the fragment in the lateral projection is eliminated by moving it, using the “bowstring” repositioning technique (Fig. 3), with simultaneous traction of the spokes with stops upward or downward, manually, or by moving them in the holes of the apparatus supports, with simultaneous traction of the spokes with tensioners for repositioning in the lateral projection.

The insertion of a pin with a thrust pad through the base, the cortical layer, of the fragment, through its center, at an angle of 90° to the base, is performed to facilitate the control of the fragment during its reposition, which allows for the creation of counter-lateral compression between the fragment and its bed.

The method of applying an external fixation device in the treatment of multi-fragmentary fractures of the femur in children is explained by the illustrations, where: Fig. 1 shows a general diagram of the insertion of spokes with stop pads;

Fig. 2 - general diagram of passing the spokes through the fragment and fragments;

Fig. 3 - Manual “gathering” of soft tissues when inserting pins into the fragments;

Fig. 4 - X-ray of a limb segment after application of the apparatus;

Fig. 5 - X-ray of a limb segment 1 month after dismantling the device;

Fig. 6 - Functional result after three months

The method is carried out as follows.

Reposition of comminuted fractures of long tubular bones begins with restoration of the biomechanical axis of the limb, its length, and elimination of rotational displacement by aligning a line conditionally drawn through the anterior superior iliac spine, the middle of the patella, and the first interdigital space. Simultaneously, displacement along the length is eliminated, and the amount of necessary elongation is determined as the difference in the length measurements of the healthy and damaged limbs, along lines drawn from the anterior superior iliac spine - the upper point, to a point 1 cm above the upper pole of the patella - the lower point. Control radiography is performed to monitor the completed reposition, determine the levels, sizes, and positions of intermediate fragments and fragments, and install "markers" in the form of injection needles. Distal and proximal base rods are inserted along the outer lateral surface of the femur into the distal and proximal bone fragments, onto which distal and proximal base supports are installed. Between them, using threaded rods, reposition supports are installed, depending on the number of fragments. Remote brackets are mounted on these supports, onto which pin fixators are installed to secure the pins with stop pads. The base supports are connected to the intraosseous rods using pin fixators and standard remote brackets.

To perform fragment reposition, two pins with support pads are inserted into each rectangular intermediate fragment perpendicular to the plane of displacement, parallel to each other, with the maximum spacing of their insertion points, placing the support pads of the pins on the fragment from the side of the displaced cortical layer opposite each other. In this case, the pins are bitten off, depending on their purpose and the position of the fragment: the sharpened part of the "pushing" pin is bitten off at an acute angle at a distance of 2 cm from the support pad, and the blunt end of the "pulling" pin is bitten off to the base of the support pad.

To reposition the fragments, a pin with a thrust pad is passed through the base, the cortical layer, of the fragment, through its center, at an angle of 90° to the base so as to create counter-lateral compression between the fragment and its bed: when the base of the triangular fragment is located on the side of the outer surface of the injured segment, the pin with a thrust pad is passed from the outside to the inside, and when the base of the triangular fragment is located on the side of the inner surface of the injured segment, the pin with a thrust pad is passed from the inside to the outside. After performing counter-lateral compression, the pins are secured to the external brackets of the device.

When the fragment is positioned at an angle to the axis of the limb segment, to insert a pin with a stop pad perpendicular to the plane of fragment displacement, the technique of "gathering" soft tissues is used, i.e., the skin with soft tissues is manually pulled together from the side of insertion of the repositioning pin, in the direction of this pin. Elimination of fragment displacement in the lateral projection is performed by moving it, with simultaneous manual traction of the pins with stops upward or downward.

The apparatus parts are secured, aseptic dressings are applied around the osteofixators. The limb is removed from the orthopedic table.

Clinical example

Patient K-va S., 14 years old, was admitted to the clinic with the diagnosis: Closed multi-fragmentary fracture of the left femur, with displacement. The injury was sustained in a traffic accident. The patient was hospitalized in the pediatric traumatology department, where a clinical and instrumental examination was performed. Preoperative planning was carried out taking into account the presence of a two-fragment fracture of the femur, on the basis of which the design of the device was individually composed.

The patient's limb was placed on the orthopedic table. Reposition of comminuted fractures of long tubular bones began with restoration of the biomechanical axis of the limb, its length, and elimination of rotational displacement by aligning a line conditionally drawn through the anterior superior iliac spine, the middle of the patella, and the first interdigital space. Simultaneously, a length displacement of 3 cm was eliminated. The amount of required elongation was determined as the difference in length measurements of the healthy (42 cm) and damaged (39 cm) limbs along lines drawn from the anterior superior iliac spine, the upper point, to a point 1 cm above the upper pole of the patella, the lower point. Control radiography was performed to monitor the completed reposition, determine the levels, sizes, and positions of intermediate fragments and splinters. Injection needles were used to install "markers" to indicate the insertion sites of the pins. Distal and proximal base rods were inserted along the outer lateral surface of the femur into the distal and proximal bone fragments, onto which the distal and proximal base supports were installed. A reposition support was installed between them using threaded rods. Remote brackets were mounted on these supports, onto which pin fixators were installed to secure the pins with stop pads. The base supports were connected to the intraosseous rods using pin fixators and standard remote brackets. To perform the reposition of the fragments, two pins with stop pads were inserted into the larger intermediate fragment, close to rectangular in shape, perpendicular to the plane of displacement, parallel to each other, with the maximum spacing of their insertion points, placing the stop pads of the pins on the fragment from the side of the displaced cortical layer, opposite each other. In this case, the sharpened part of the "pushing" pin was bitten off at an acute angle at a distance of 2 cm from the stop pad, and the blunt end of the "pulling" pin was bitten off to the base of the stop pad. Since the fragment was located at an angle to the axis of the limb segment, the technique of "gathering" soft tissues was used to insert the pin with the stop pad perpendicular to the plane of fragment displacement: the skin with soft tissues was manually pulled together from the side of the insertion of the repositioning pin, in the direction of this pin. The displacement of the fragment in the lateral projection was eliminated by moving it, with simultaneous downward traction of the spokes with stops, manually.

To reposition the fragment, a pin with a thrust pad was passed through the base, the cortical layer, of the fragment, through its center, at an angle of 90° to the base so as to create counter-lateral compression between the fragment and its bed: when the base of the triangular fragment was located on the side of the outer surface of the injured segment, the pin with a thrust pad was passed from the inside to the outside. After performing counter-lateral compression, the pins were secured to the external brackets of the apparatus. All parts of the apparatus were secured, aseptic dressings were applied around the osteofixators (Fig. 4).

On the fifth day, the patient was allowed a dosed load of up to 10 kg per limb. The patient was taught dosed walking on floor scales. The patient was discharged from the hospital on the 15th day after the operation. Examination was performed 1, 3, and 5 months after the operation. Five months after the application of the apparatus, consolidation of the fragments was achieved, and the apparatus was dismantled. One month after dismantling the apparatus, an X-ray of the limb segment was taken (Fig. 5); Fig. 6 - Functional result three months after dismantling the apparatus.

The patient was examined five years later: no complaints, no shortening of the femoral segment, the biomechanical axis of the limb completely restored, movements in adjacent joints are fully determined.

Conclusions:

1. When repositioning multi-comminuted fractures of the femur in children, in addition to eliminating the lengthwise and rotational displacement, the primary task is to restore the biomechanical axis of the limb using neutral osteosynthesis technology.

2. Restoration of the biomechanical axis of the segment, even with previously unresolved displacement in width, at an angle, due to the functional activity of the growth zones, leads to a complete transformation of the bone.

Sources of information:

1. Patent of the Russian Federation No. 2317036, A61B 17/56, Bulletin 34, 2006;

2. Patent of the Russian Federation No. 2338480, A61B 17/56, Bulletin 32, 2008;

3. Lashkovsky, V. V. Self-correction of residual deformities in fractures of long tubular bones of the upper limb in children [Electronic resource] / V. V. Lashkovsky // Current state of children's health: collection of materials of the IV regional scientific and practical conference with international participation, April 14-15, 2016 / Grodno State Medical University; edited by N. S. Paramonova; [editorial board: V. V. Vorobyov, N. S. Paramonova (editors), N. A. Maksimovich]. - Grodno, 2016. - P. 143-146. - 1 el. opt. Disk;

4. Patent of the Russian Federation No. 2629050, A61B 17/56, Bull. 24, 2017.

5. Scientific discovery "General biological property of tissues to respond to dosed stretching with growth and regeneration (Ilizarov effect)", No. 355, November 24, 1970. Date of registration: September 15, 1988.

Claims (2)

1. A method for treating comminuted fractures of the femur with a rod apparatus in children, including the introduction of 2 intraosseous rods into the proximal and distal fragments, mounting proximal and distal supports on them in the form of curved plates, connecting the supports with threaded rods located parallel to the direction of the bone fragments, installing bone rods in external rod fixators secured to the said supports, and fixing an intermediate repositioning support on the threaded rods, characterized in that the reposition of comminuted fractures of long tubular bones begins with the restoration of the biomechanical axis of the limb, its length, and the elimination of rotational displacement by aligning a line conditionally drawn through the anterior superior iliac spine, the middle of the patella and the first interdigital space, while simultaneously eliminating the displacement along the length, while the amount of necessary elongation is determined as the difference in measurements lengths of the healthy and damaged limbs, along lines drawn from the anterior superior iliac wing spine - the upper point, to a point 1 cm above the upper pole of the patella - the lower point, a control radiography is performed to monitor the completed reposition, determine the levels, sizes, and positions of intermediate fragments and fragments, install "markers" in the form of injection needles, distal and proximal base rods are inserted along the outer lateral surface of the thigh into the distal and proximal bone fragments, on which the distal and proximal base supports are installed, between them, using threaded rods, reposition supports are installed, depending on the number of fragments, remote brackets are mounted on these supports, on which pin fixators are installed to secure the pins with stop pads, the base supports are connected to the intraosseous rods using pin fixators and standard remote brackets, for to perform reposition of fragments, two pins with thrust pads are inserted into each rectangular intermediate fragment perpendicular to the plane of displacement, parallel to each other, with the maximum spacing of the points of their insertion, placing the thrust pads of the pins on the fragment from the side of the displaced cortical layer opposite each other, while the pins are bitten off, depending on their purpose and the position of the fragment: the sharpened part of the “pushing” pin is bitten off at an acute angle at a distance of 2 cm from the thrust pad, and the blunt end of the pulling pin is bitten off to the base of the thrust pad; to reposition fragments, a pin with a thrust pad is inserted through the base - the cortical layer, of the fragment, through its center, at an angle of 90 ° to the base so as to create counter-lateral compression between the fragment and its bed: when the base of a triangular fragment is located on the side of the outer surface of the injured segment ... into the base of the fragment, through the center of the fragment, at an angle of 90 ° to the base so as to create counter-lateral compression between the fragment and its bed: when the base of a triangular fragment is located on the side of the outer surface of the injured segment, a pin with a thrust pad is inserted into the base of the fragment, through the center of the fragment, at an angle of 90 ° to the base so as to create counter-lateral compression between the fragment and its bed: when the base of a triangular fragment is located on the side of the outer surface of the injured segment, a pin with a thrust pad is inserted into the base of the fragment, through the center of the fragment, at an angle of 90 ° to the base, so as to create counter-lateral compression between the fragment and its bed: when the base of a triang the platform is carried out from the outside to the inside, and when the base of the triangular fragment is located on the side of the inner surface of the injured segment, the spoke with a thrust platform is carried out from the inside to the outside, after performing counter-lateral compression, the spokes are secured to the external brackets of the device. 2. The method according to item 1, characterized in that when the fragment is positioned at an angle to the axis of the limb segment, to insert a pin with a stop pad perpendicular to the plane of displacement of the fragment, the technique of “gathering” soft tissues is used, that is, the skin with soft tissues is manually pulled together from the side of the insertion of the repositioning pin, in the direction of this pin, the displacement of the fragment in the lateral projection is eliminated by moving it, with simultaneous manual traction of the pins with stops upward or downward.