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EXPERIENCE OF SURGICAL RESTORATION OF ANNULAR LIGAMENT WITH DISLOCATIONS OF RADIAL BONE HEAD
IN CHILDREN Eranov Sh.N.1, Eranov N.F.2
1Eranov Sherzod Nuraliyevich - Assistant;
2Eranov Nurali Fayziyevich - Assistant, DEPARTMENT OF TRAUMATOLOGY AND ORTHOPEDICS, SAMARKAND STATE MEDICAL INSTITUTE, SAMARKAND, REPUBLIC OF UZBEKISTAN
Abstract: in this article is analyzed the result of treatment of 83 patients with radial bone head sprains. The joint capsule itself and the sections of the ring-shaped ligament, which is more anatomical and physiological concerning the elbow joint, were used for rehabilitation of the ring-shaped ligament. The results were evaluated on a scale of "Evaluation of elbow surgery". The scale allows us to determine the severity of pain syndrome, the amplitude of movements in the elbow joint, the condition of the joint, the strength of the arm and the degree of daily living activity. Good and excellent results with an evaluation after 6, 12 months (>70 points) were obtained in 56 patients, which was 57.4%, satisfactory results (50-69points) were observed in 26 (31.3%).
Keywords: dislocation of the radius head, annular ligament, Monteggia fracture.
Relevance. At present, children's and adolescents' injuries are becoming one of the main problems of the medical and biological plan due to the increase in the number and severity of injuries. Elbow joint injuries in children, according to various authors, account for 40 to 50% of all musculoskeletal injuries. And post-traumatic complications as a result of elbow joint injuries occupy the first place and in 29.9% of cases lead to persistent disability of patients [1, 3, 4].
In terms of the frequency of errors and complications in the treatment of injuries in this area, they take the first place relative to other joints forming the elbow joint, which requires a more thorough and detailed study [2,5]. Unsatisfactory results of treatment of elbow joint injuries remain high to date, reaching 21% and have no tendency to decrease [6, 7]. It is not uncommon to treat elbow joint injuries as concomitant lesions in a distant time when good results are no longer possible [8, 9, 10, 11]. There is practically no scientific literature covering the tactics of treating old injuries to the shoulder-radial joint. All this indicates the need to further explore of more optimal options for surgical restoration of the annular ligament in case of its damage.
The goal: restoration of the annular ligament in case of various dislocations of the head of the radial bone in children according to our method.
Materials and methods. Our report is based on the study of the results of treatment of 83 children who were in hospital from 2017 to 2019. Of these, isolated dislocations were in 62 patients (74.6%), with injuries to Montagge in 21 patients (25.4%). There were 54
(65.1%) boys and 29 (34.9%) girls. The lesions localized to the right in 41, left in 39 and bilateral in 3 patients. By age: up to 5 years - 22 patients, 6-12 years - 46 patients, 13-18 years - 15 patients.
The following operative methods of treatment have been performed for patients:
- Open reposition of the head of the radial bone, with reconstruction of the annular ligament - in 52 patients;
-Osteosynthesis of the ulnar bone, open reposition of the head of the radial bone with reconstruction of the annular ligament - in 21 patients;
-Osteotomy of ulnar bone, open adjustment of the head of the radial bone with reconstruction of the annular ligament - in 10 patients.
Surgery technique: lateral access, 2 cm above the outer epicondyle through the joint, 4 cm into the forearm area. Hypodermic cellulose unseparated. Muscles attached to the outer supersaturus are dissected from the front, from the bottom, from the rear of the supersaturus. Shoulder condyle head is visible. Tendon - capsule soft tissue is dissected laterally and longitudinally 1-1,5cm in order to expose the head of the radial bone. When such dissection is performed, damage to the r.profundus branch of the radial nerve cannot still be feared. The superficial layer of the muscle of the radial neck region is dully moved medially, a deep branch of the radial nerve is found in the thickness of the supinator muscle. It is exposed to the anterior joint capsule - it is necessary to cut out the flap capsule safely to recreate the annular ligament.
Usually, the sites of the radial-elbow joint will be filled with scar tissues. It is acutely separated from the ulnar bone, starting from the center to the periphery, towards the residue of the annular ligament, at the posterior edge of the ulnar incision. The head is displaced to the native place, adheres by pressing to the back with the newly formed ligament (flap from the capsule), the degrees of fixation of the radial head during bending, extension, rotation of the forearm are checked. Flap is cut out to create annular ligament from anterior surface of joint capsule. The direction of the incision to the internal boundary of the head of the radial bone goes horizontally, then changes direction to the distal side, towards the anterior edge of the radial incision of the ulnar bone, where, usually, the annular ligament is naturally attached. Thus, in the thickness of the formed flap there is also an annular ligament itself. The flap is laid on the neck region of the radial bone and attached by stitching to dense fibrous tissue at the posterior edge of the radial incision of the ulnar bone. The head of the radial bone after adjustment continues to maintain a tendency towards anterior, medial displacement, which creates a load on the formed similarity of the annular ligament. Therefore, in order to prevent its stretching and possible recurrence of dislocation, additional temporary immobilization by Kirchner 's wire is carried out through the head elevation of the shoulder and head of the radial bone. Layer-by-layer suture. In the postoperative period, immobilization with plaster splint lasted up to 3 weeks in the position of supination. Then patients received a course of iodide potassium electrophoresis, therapeutic gymnastics, massage.
Results and discussion: Analysis of treatment results was carried out by clinical and X-ray methods. The results were evaluated on the Elbow Surgery Score scale. The scale makes it possible to determine the manifestations of pain syndrome, the amplitude of movements in the elbow joint, the condition of the joint, the strength of the hand and the degree of daily domestic activity. The maximum score (100) on this scale corresponds to a healthy elbow joint. Good and excellent results were obtained after 6. 12 months (> 70 points) in 56 patients, which was 57.4%, satisfactory results (50-69 points) were observed in 26 (31.3%). Relapse in the form of a subluxation was observed in 1 child.
When performing open a reposition of the head of the radial bone in children, with old trauma, we consider it appropriate to pay attention to the following points:
- Creating of the annular ligament of the radial bone from the anterior capsule of the ulnar joint;
- Excision of scar tissue from radial incision of ulnar bone.
Thus, in case of changes in the shoulder joint during the surgical intervention, it was shown that the joint capsule was located between the head of the radial bone and the joint end of the shoulder. Similar changes were observed in 80% or more patients. Such changes cast a new light on a problem of pathology of old dislocations of the radial head and justify the proposed tactics of operative treatment of patients.
Conclusion: The reasons for old dislocations of the radial head are explained by errors of diagnosis, untimely medical care concerning the treatment of patients, when the parents of the patients considered the trauma not serious. To recreate the ring ligament, we used the joint capsule itself and sections of the annular ligament, which is more anatomical-physiological one with respect to the elbow joint. Surgical treatment of children with dislocations of the head of the radial bone, reconstruction of the ring ligament, transarticular fixation of the head of the beam, allowed us to achieve good and satisfactory functional results in 96.4% of cases, and anatomical - in 94.7% of cases.
References
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