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Salokhiddinov Fakhriddin Bakhriddinovich, Tashkent Medical Academy Assistant, Department of "Traumatology-Orthopedics, MFS № 1"
E-mail: fb.doc@mail.ru Karimov Murodullo Yuldashovich, Tashkent Medical Academy Professor, Chief of Department "Traumatology-Orthopedics, MFS № 1"
E-mail: m.karimov@mail.ru
THE RESULTS OF SURGICAL TREATMENT OF LONG BONE FRACTURES WITH MULTIPLE AND ASSOCIATED INJURIES
Abstract: For multiple and combined injuries against the background of anti-shock measures and stabilization of hemodynamic indicators, urgent and delayed surgical interventions on the damaged limbs should be performed depending on the severity of the injury and the patient's condition.
From 2011 to 2016, here were conducted operative and conservative treatment of 125 patients with open and closed fractures of long bones with multiple and combined injuries. The average age varied from 25 to 72 years. Of these, men - 78 (62.4%), women - 47 (37.6%). The majority of patients, which comprised 109 patients (87.2%), were persons of working age.
According to the type of damage, the distribution was carried out according to the AO-ASIF classification as follows: A1-32; A2-15; A3-2; B1-8; B2-6; C1-26; C2-28; C3-8. In this case, fractures of the femur were observed in 56 patients; In 69 patients there was a fracture of the shin bones.
Patients were divided into 2 groups: basic and control. The main group consisted of47 (37.6%) patients who received early stable osteosynthesis of long bone fractures in the first three days after the trauma. The control group consisted of78 (62.4%) patients who had osteosynthesis in a delayed and planned manner.
When studying the long-term results in the two groups the following results were obtained. In the main group: good results were found in 34 (91.5%) patients, satisfactory results - in 3 (6.4%), poor - in 1 (2.1%) patient. In the control group: good results were found in 47 (85.45%) patients, satisfactory results - in 3 (5.45%), poor - 5 (9.1%) patients.
When choosing the timing and scope of surgical treatment, the "damage control" requirements must be taken into account. It is also mandatory to perform massive intensive care and give preference to low-injury external fixation devices.
Early intervention reduces mortality and complications in patients with combined and multiple injuries of the musculoskeletal system.
Keywords: polytrauma, early osteosynthesis, external fixation apparatus.
Relevance traumatology, orthopedics, because of the severity of
Year by year, due to the population urbanization, her condition, compounded by a combination of bone the emergence of high-speed mechanisms and increase fractures of extremities with other anatomical structures. of vehicles, increasing the number of patients with These injuries are very hard for victims who are bedrid-multiple and associated trauma is an important task of den, which is one of the main causes of early and late
complications (hypostatic pneumonia, pressure ulcers, phlebitis, cardiovascular and respiratory failure, non-fracture, false joints, etc.) [1; 2; 3].
For multiple and combined injuries against the background of anti-shock measures and stabilization of hemodynamic indicators, urgent and delayed surgical interventions on the damaged limbs should be performed depending on the severity of the injury and the patient's condition. However, conducting an operation creates additional difficulties for multiple and combined injuries when performed according to vital indications, where the time factor plays a big role in saving the patient's life. This is due to the fact that with multiple and combined injuries, the severity of the condition of the affected is determined by shock, internal damage, bleeding and traumatic brain injury. That is why various authors believe that first of all, it is necessary to perform surgical interventions to save the life of the patient (stop bleeding, surgery on damaged internal organs, etc.) [4; 5]. In such cases, some authors [6] propose their own design, preventive immobilization by the EFD-PI rod apparatus. After stabilization of hemodynamics of the victim, he is transferred to medical immobilization.
The problem of treating victims with multiple and combined injuries, over the past decades has become the most urgent task of traumatology and orthopedics. This is due to high rates of mortality, disability and long rehabilitation periods [7]. Also, the issue of determining the timing of surgical treatment for multiple and combined injuries remains unresolved [8; 9].
Foreign authors, in order to reduce the lethality, recommend a stage treatment "damage control", which allows to obtain good results [11]. In case ofsevere general condition, according to the "damage control" law, the treatment measures performed should be minimally traumatic, rapid stabilization in severe hemodynamically unstable victims, allows to stabilize the general and local condition, providing subsequent reconstructive treatment [17].
According to the results of A. V. Bondarenko, OA Gerasimova and A. G. Goncharenko, carrying out osteosynthesis in combination with trauma in the first three weeks after trauma, is the optimal time and significantly reduces hospital mortality, which allows early activation of patients [10]. The primary treatment procedure should be minimally traumatic and short-term, so as to minimize the effect on the general condition of the
patient, as well as on the condition of the injured limb [16; 19]. The main cause of complications is the hypo-dynamic state ofpatients caused by the trauma itself and the method of its treatment [15; 16].
Currently, in the treatment of patients with polytrauma, significant progress has been made. Osteosynthesis by rod devices is less traumatic, the risk of damage to the vascular nerve trunks is reduced due to their one-sided arrangement. Rod devices have a rigid fixation ofbone fragments, they are compact, easier to install and install and significantly reduce the time of surgery. In addition, rod devices create optimal conditions for fracture healing [12; 13; 19]. Stabilization of fractures with polytrauma, contributes to early activation and prevention of secondary complications, which is of great importance for patients [15; 18].
The purpose of research: analysis of the results of surgical treatment of fractures of long bones, depending on the duration and severity of injury in multiple and associated injuries.
Material and methods of investigation
For the period from 2011 to 2016, we performed operative and conservative treatment in 125 patients with open and closed fractures oflong tubular bones with multiple and combined injuries. The age of the patients ranged from 25 to 72 years. The men were 78 (62.4%), women - 47 (37.6%). Among the total number, 109 patients (87.2%) were persons of working age. According to the mechanism of injury, the patients were distributed as follows: households - 25 (20%), industrial - 11 (8.8%), street - 4 (3.2%), as a result ofroad accidents - 78 (62.4%), Katatrauma - 4 (3.2%) and in sports - 3 (2.4%). Closed fractures accounted for 82 cases (65.6%), open fractures - 43 (34.4%). Femoral fractures were observed in 56 patients, in 69 patients there was a fracture of the shin bones. According to the type of damage, the distribution was carried out by the classification of AO-ASIF [14] as follows: A1-32, A2-15, A3-2, B1-8, B2-6, C1-26, C2-28, C3-8 cases. In 69 patients fractures were combined with craniocerebral trauma, fracture of pelvic bones in 13 patients, thoracic organs damage in 12 patients, abdominal organs in 30 patients, peripheral nerve injuries of upper extremities in 1 patient. 62 injured (49.6%) had a traumatic shock ofvarying degrees.
Patients distribution criterion was the scale of assessment of the severity of injuries of the TS (1981) and
assessment of severity of the Glasgow Coma Scale of traumatic brain injury (1974). The severity of the condition was as follows: 3-7 points in 13 patients (10.4%), in 28 patients (22.4%), the severity of the injury was estimated at 8-10 points, 11-15 points in 37 (29.6%) and 16 points in 47 (37.6%) patients. It should be noted that 41 patients (32.8%) had a serious and extremely serious condition when they were admitted. The state of severity of the victims with multiple and combined injuries was aggravated by fractures of bones, degrees of traumatic shock and the magnitude of blood loss.
To provide emergency assistance, a team of specialists consisting of a traumatologist, a surgeon, a neurosurgeon and an intensive care specialist was involved, temporary immobilization of the damaged limbs with plaster bandages or standard tires was carried out, the severity of the patient's condition and the severity of the injury were assessed and, based on this, the tactics of the medical and diagnostic measures were planned. The question of the time and amount of the operative intervention was decided, depending on the severity of the trauma and the severity of the patient's condition. The examination included radiography of the skull, chest and pelvic bones, ultrasound examination (ultrasound) of the abdominal organs. If necessary, magnetic resonance imaging (MRI) or multispiral computed tomography (MSCT) was used for additional information. When deciding on the method of fixing fractures, the nature of the fracture and the number of damaged segments were taken into account. Patients were divided into 2 groups: primary and control. The main group consisted of 47 patients (37.6%) who received early stable osteosynthesis of fractures of long bones in the first three days after the trauma. The control group consisted of 78 patients (62.4%) who had osteo-synthesis in a delayed and planned manner.
Results and its discussion
Patients of the main group in the first 3 days, against the background of anti-shock measures and condition severity of the injury TS 10-16 points, held a variety of surgical procedures. In the first 6 hours 12 patients (25.5%) on a background therapy of antishock and 13 patients (27.7%) after the infusion, transfusion therapy, stabilization of hemodynamics and general condition, produced osteosynthesis of long bones external fixation devices (EFD) Extramedullary osteosynthesis by the plate, intramedullary osteosynthesis, including blocking intramedul-
lary osteosynthesis (BIN). In 12 patients (25.5%) with concomitant damage to the abdominal organs and limbs, the operation performed by two teams surgery - laparotomy with stitching breaking parenchymatous organs and stabilization ofbone fractures rod device or compression-distraction osteosynthesis device of Ilizarov. Due to the severity of the condition (the degree of injury of TS 3-7 points) 10 patients (21.3%) with fractures in the first day the treatment was conducted conservatively, including 8 patients after stabilization of hemodynamic parameters, and general condition, held preventive surgery. In the intensive care unit, in the absence of acute surgical interventions on the organs of the abdominal cavity and head, a rod apparatus was used to fix the injured extremities. In a combined trauma with fractures of the pelvic bones, six patients underwent spinal-osteosynthesis. After the exit of patients from the critical condition, the final osteosynthesis was carried out with the help of the stem apparatus in 4 patients (8.51%), bone osteosynthesis was performed by 2 patients (4.25%), BIN - 2 patients (4.25%). In 2 cases (4.25%), due to the severity of the injury on the 3-5 days, lethal outcome was observed.
We have developed rod device (patent FAP 00737 08.06.2012). Time to impose the device took 20-30 minutes and did not require a special operating room. The application of the External Fixation Device (EFD) has the following positive aspects: facilitating the care of severe and comatose patients, monitoring the skin condition, preventing bedsores and painful syndrome of damaged limbs. In addition, the use of EFD is a prophylaxis of complications observed in skeletal traction, such as heart overload, increased central venous pressure, high diaphragm standing and reduced excursion, general hypokinesia, immobilization of the injured limb.
The control group mainly used methods of conservative treatment. Severity ofTS trauma patients was estimated at 8-16 points. In 18 patients (23.1%) with combined abdominal injury, laparotomy was performed with suturing the rupture of parenchymal organs, thoracocentesis was performed in 16 cases (20.5%). Damaged limbs were fixed with plaster bandages. Since the moment of the injury in case of open fractures, produced primary surgical treatment of wounds with the osteosynthesis rod device in 7 cases (8.97%), compression-distraction osteosynthesis Ilizarov - 5 cases (6.41%), with needles - y 7 Ofpatients (8.97%). In delayed-routinely produced extramedullary
osteosynthesis plate in 17 cases (21.79%), intramedullary osteosynthesis - 11 (14,1%), BIN (Blocked intramedullary nailing) - in 17 cases (21.79%). Also, a needle-shaft apparatus was applied to the pelvic bone in 7 patients. In 8 patients (12.3%) continued conservative treatment, because On the control radiography the standing of the bone fragments was satisfactory. In 1 case, with a fractured fracture of the head of the right humerus with traumatic separation of the vessels and brachial plexus, autovenous plastic of the brachial artery was performed. Also in 1 case with a fracture of the femur with femoral artery damage, according to vital indications, the right lower limb was
amputated at the level of the upper third of the thigh. Mortality despite the intensive intensive care measures was 6 cases (7.69%). The cause of death was an extremely difficult condition for admission of patients, instability of hemodynamics complicated by ARDS, thrombotic and fat embolism, cardiovascular and respiratory insufficiency.
To illustrate, there is given a clinical example. Patient H., 28 years old, catatrauma. At admission, the following is diagnosed: Combined trauma. CCSI. Concussion of the brain. An open comminuted fracture with/3 bones of the left shin with a mix of k/o (according to the AS/ASIF classification - 42.A2.3) (Fig. 1).
Figure 1. X-ray image at the admission. Figure 2. The X-ray after the operation
Figure 3. The X-ray imageafter 16 weeks. Figure 4. The X-ray image of the patient after 2 years
After the preoperative preparation, the Initial Surgical D-bridement of the wound with osteosynthesis of the bones of the left calf with the stern apparatus
of the clinic was performed 12 hours after the injury (Fig. 2). The residual displacement of the fragments, revealed on the control radiograph, was eliminated at
subsequent stages. On the 3rd day after the trauma the patient started the course of rehabilitation measures. The postoperative period was uneventful, which allowed the patient to be discharged from the hospital in satisfactory condition on day 10. After 16 weeks, bone fragments were fused (Figure 3), after which the apparatus was dismantled. At a control examination after
2 years on the roentgenogram (Figure 4), complete consolidation of fractures of the shin bones was noted, walking does not show any complaints, movement in the knee and ankle joints in full, a good anatomical and functional result is noted.
The analysis of literature sources showed that the main cause of complications is the hypodynamic state of patients caused by the trauma itself and the method of its treatment, which was confirmed in our studies.
To assess the outcome of treatment outcomes, the evaluation system of the ER was used. Long-term results of treatment were studied in 93 patients in terms of 12 to 26 months. When studying the long-term results in the two groups the following results were obtained. In the main group: good results were established in 34 patients (91.5%), satisfactory - in
3 (6.4%), unsatisfactory - in 1 (2.1%) patients. In the control group revealed good results in 47 cases (85.45%), satisfactory - in 3 (5.45%), poor - in 5 cases (9.1%) (p < 0.05).
Conclusion
Patients in the control group experienced complications against the background of an acute period of traumatic disease, hemorrhage, hypovolemic shock and multiple organ failure. Severe complications such as thrombotic and fatty embolism were noted in 6 patients (7.69%) and only in 2 cases (4.25%) in the main group. In 2 patients (4.25%) of the main group and 6 (7.69%) in the control group were noted nfektsionnye complications. Hypostatic pneumonia was observed in 4 patients (8.5%) from the main group and in 10 patients (12.8%) from the control group. Sacral bedsores, heel and shoulder area of the main group were only observed in 1 case (2.1%), while in the control group, 7 patients (8.97%).
In the study of dynamics observation remote results in the two groups the following results were obtained. In the main group: good results were established in 34 patients (91.5%), satisfactory - in 3 (6.4%), unsatisfactory - in 1 (2.1%) patients. In the control group revealed good results in 47 cases (85.45%), satisfactory -in 3 (5.45%), poor - in 5 cases (9.1%) (p < 0.05).
When choosing the timing and scope of surgical treatment, the "damage control" requirements must be taken into account. Also a must is to conduct a massive and intensive care to give preference to low-invasive external fixation devices.
Conducting the early surgery reduces mortality rates and the number of complications in patients with combined and multiple injuries ofthe musculoskeletal system.
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