RU2835501C1 - Method for closed reduction of fracture of distal radial bone using antegrade intramedullary metal osteosynthesis with curved k-wire in children - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to traumatology-orthopaedics, and can be used for treating distal radius fractures in children. Proximal end of K-wire with feather double-sided sharpening is bent by 30° towards sharpening; at a proximal epiphysis of a radial bone in a middle physiological position of an injured extremity a hole is formed in a medullary canal. Pin end is inserted into the medullary canal and brought under the control of the C-arm to the fracture site. Closed manual fracture reduction is performed; preserved mixing of bone fragments is eliminated by axial rotation of the wire by the free end to achieve anatomical reduction. Under the control of the C-arm, the K-wire is fixed in the distal fragment.

EFFECT: method provides higher accuracy of reduction, reduced risk of developing intra- and postoperative complications due to reposition by specially prepared K-wire.

1 cl, 6 dwg, 2 ex

Description

The invention relates to medicine, namely to traumatology-orthopedics, and can be used to treat fractures of the distal radius in children.

As an analogue, we accept the methods described in publications (Abulsoud M.I., Mohammed A.S., Elmarghany M., et al. Intramedullary Kirschner wire fixation of displaced distal forearm fractures in children // BMC musculoskeletal disorders. 2023. Vol. 24. N 1. P. 746. doi: 10.1186/s12891-023-06875-z), which reflect that distal radius fractures (DRF) are common in childhood. Surgical treatment of DRF fractures is recommended in the presence of the following indications: ineffectiveness of closed reposition, fracture instability, secondary displacement of fragments, refractures, polytrauma. In this case, minimally invasive osteosynthesis should be the method of choice during surgical treatment. Today, the "gold standard" of surgical treatment of displaced distal forearm fractures in children is closed reduction and intramedullary metal osteosynthesis with Kirschner wires followed by the application of a plaster cast (Abulsoud M.I., Mohammed A.S., Elmarghany M., et al. Intramedullary Kirschner wire fixation of displaced distal forearm fractures in children // BMC musculoskeletal disorders. 2023. Vol. 24. N 1. P. 746. doi: 10.1186/s12891-023-06875-z). The advantages of this method are that it is technically minimally demanding, minimally invasive and does not require special equipment (Pavone V., Vescio A., Lucenti L., et al. Analysis of loss of reduction as risk factor for additional secondary displacement in children with displaced distal radius fractures treated conservatively // Orthop. Traumatol. Surg. Res. 2020. Vol. 106. P. 193-198. doi: 10.1016/j.otsr.2019.10.013). It has been proven that fixation with Kirschner wires significantly improves stability in the fracture zone and sharply reduces the risk of re-displacement compared to closed reduction followed by plaster casting. The standard method of inserting Kirschner wires is the retrograde method, in which the wire is inserted through the distal fragment of the radius (Nietosvaara Y., Hasler C., Helenius I., Cundy P. Marked initial displacement predicts complications in physeal fractures of the distal radius: an analysis of fracture characteristics, primary treatment and complications in 109 patients // Acta Orthop. 2005. Vol. 76. N. 6. P. 873-877. doi: 10.1080/17453670510045525; Jordan R.W., Westacott D., Srinivas K., Shyamalan G. Predicting redisplacement after manipulation of paediatric distal radius fractures: the importance of cast moulding // Eur. J. Orthop. Surg. Traumatol. 2015. Vol. 25. N. 5. P. 841-845. doi:10.1007/s00590-015-1627-0).

In 2002, specialists from Japan proposed a technique in which Kirschner wires are inserted antegradely, which reduces the risk of complications (Wendling-Keim D.S., Wieser B., Dietz H.G. Closed reduction and immobilization of displaced distal radial fractures. Method of choice for the treatment of children? // Eur. J. Trauma Emerg. Surg. 2015. Vol. 41. N. 4. P. 421-428. doi: 10.1007/s00068-014-0483-7). This technique has proven its effectiveness and is used in adult patients abroad (Japan, India) (Wendling-Keim D.S., Wieser B., Dietz H.G. Closed reduction and immobilization of displaced distal radial fractures. Method of choice for the treatment of children? // Eur. J. Trauma Emerg. Surg. 2015. Vol. 41. N. 4. P. 421-428. doi: 10.1007/s00068-014-0483-7; Aladraj T.N., Keshta A.S., Mukhtar I., et al. A Retrospective Cohort Study Comparing the Outcomes of Conservative Versus Operative Fixation of Distal Radius Fractures in Children // Cureus. 2022. Vol. 14. N 2. P. e22544. doi: 10.7759/cureus.22544; Wollkopf A.D.P., Halbeisen F.S., Holland-Cunz S.G., Mayr J Diametaphyseal Distal Forearm Fractures in Children: A STROBE Compliant Comparison of Outcomes of Different Stabilization Techniques Regarding Complications // Children. 2023. Vol. 10. N. 2. P. 374. doi: 10.3390/children10020374). However, the use of this method in pediatric practice has not been described to date. In addition, this method does not eliminate the residual displacement of bone fragments in the fracture zone after reposition, since it only involves fixing the fracture with a Kirschner wire after closed manual reposition, which makes it difficult to eliminate the width displacement.

The essence of the invention lies in a set of distinctive features sufficient to achieve the desired technical result, and consists in increasing the effectiveness of repositioning with a Kirschner wire of fractures of the distal radius in children by improving the repositioning technique.

The essence of the invention is that the proximal end of a Kirschner wire with a feather double-sided sharpening is bent by 300 in the direction of sharpening; an opening into the medullary canal is formed at the proximal epiphysis of the radius in the midphysiological position of the injured limb; the end of the wire is inserted into the medullary canal and, under the control of a C-arm, it is advanced to the fracture site; closed manual reposition of the fracture is performed; the persistent displacement of bone fragments is eliminated by axial rotation of the wire by the free end until anatomical reposition is achieved; under the control of a C-arm, the Kirschner wire is fixed in the distal fragment. The method allows to increase the accuracy of reposition, reduce the risk of developing intra- and postoperative complications. Bending the Kirschner wire by 30° towards the sharpening side allows to avoid the abutment of its free end, oriented distally, against the cortical surface of the radius bone, and thus to perform axial rotation of the wire without hindrance.

The method is illustrated. Fig. 1 Kirschner wire - shows the Kirschner wire we use with a feather double-sided sharpening, the proximal end of which is bent by 30° towards the sharpening. Fig. 2 shows the Kirschner wire installation diagram: A - the insertion site of the wire, B - the direction of the wire installation.

Figures 3 and 4 show radiographs of the clinical case before and after repositioning using the proposed method, respectively. Figures 5 and 6 show photographs of the clinical case illustrating the main stages of repositioning using the proposed method.

The method is carried out as follows.

Taking into account the data of radiographic and clinical examination of the injured limb, the forearm is set in the mid-physiological position. In the projection of the radius, at a distance of 2-3 cm from the proximal epiphysis, a skin incision up to 1.0 cm is made. The proximal end of the Kirschner wire with a double-sided feather sharpening is bent by 30° towards the sharpening; at the proximal epiphysis of the radius in the mid-physiological position of the injured limb, an opening is formed into the medullary canal; the end of the wire is inserted into the medullary canal and, under the control of the C-arm, it is advanced to the fracture site; closed manual reposition of the fracture is performed; the persistent displacement of the bone fragments is eliminated by axial rotation of the wire by the free end until the anatomical reposition is achieved; under the control of the C-arm, the Kirschner wire is fixed in the distal fragment. A load test is performed. The proximal end of the needle is bent at an angle of 90°, the needle is cut off using nippers as close to the bone as possible, and the wound is sutured.

Clinical example 1.

Patient Shch.A.S., 8 years old, was admitted to the Ivano-Matreninskaya City Children's Clinical Hospital (Irkutsk) in August 2021 upon referral from the emergency room. His medical history included a fall on his left forearm in the street. Initial radiographs revealed a fracture of the distal left radius with a 3 mm lengthwise displacement and a 2/3 widthwise displacement of the bone diameter. At the Central Regional Hospital, an attempt was made at closed reposition and the application of plaster splints. Clinical examination revealed severe soft tissue swelling in the area of injury and limb deformity.

Under general anesthesia, closed reposition of the fracture of the distal radius was performed in the operating room using antegrade intramedullary metal osteosynthesis with a curved Kirschner wire.

Plaster immobilization for 4 weeks, then - development of movements. During the control examination 1.5 months after the injury, a full range of motion in the wrist joint was observed, similar to the range of motion in the contralateral joint.

Clinical example 2.

Patient Ya.I.A., 12 years old, was admitted to the Ivano-Matreninskaya City Children's Clinical Hospital (Irkutsk) in November 2021 upon referral from the emergency room. His medical history included a fall on his right forearm in the street. In the central district hospital, initial radiographs revealed a fracture of the radius without displacement, and plaster splints were applied. Control radiographs after removing the plaster splints revealed a fracture of the distal left radius with a displacement at an angle of 32° and the formation of a bone callus. Clinical findings included moderate pain in the area of injury and limb deformity.

Under general anesthesia, closed reposition of the fracture of the distal radius was performed in the operating room using antegrade intramedullary metal osteosynthesis with a curved Kirschner wire.

Plaster immobilization for 4 weeks, then development of movements. During the control examination 1.5 months after the injury, a full range of motion in the wrist joint was observed, similar to the range of motion in the contralateral joint.

The Kirschner wire was removed in February 2022 (4 months after surgery), and complete fracture consolidation was achieved.

The advantages of our method are minimally invasive, high aesthetic results, allows for increased accuracy of reposition, and reduces the risk of intra- and postoperative complications.

Claims (1)

A method of closed reposition of a fracture of the distal radius using antegrade intramedullary metal osteosynthesis with a curved Kirschner wire in children, characterized in that the proximal end of the Kirschner wire with a feather double-sided sharpening is bent by 30° towards the sharpening; an opening into the medullary canal is formed at the proximal epiphysis of the radius in the midphysiological position of the injured limb; the end of the wire is inserted into the medullary canal and, under C-arm control, it is advanced to the fracture site; closed manual reposition of the fracture is performed; persistent displacement of bone fragments is eliminated by axial rotation of the wire by the free end until anatomical reposition is achieved; under C-arm control, the Kirschner wire is fixed in the distal fragment.