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Shukurov Esondavlat, Candidate of Medical Sciences, Scientific Research Institute of Traumatology and Orthopedic, Uzbekistan, senior researcher E-mail: ludmilamedlib@ mail.ru
Ultrasound diagnosis of the lower extremity deep vein thrombosis in the patients with multiple fractures of the bones of the lower extremities
Abstract: There has been developed algorithm ofdiagnosis, choice ofthe technique oftreatment (N DGU2011 0174.28.07.11) and program (N DGU 2011 0188. 04. 08. 11) for prognosis of the complications of multiple fractures of the bones of lower extremities which were proved by patents. There has been performed analysis of treatment of 120 patients with bone fractures of lower extremities who were examined with ultrasound dopplerography of the lower extremities during the period from 2010 t0 2014. The algorithms proposed for diagnosis and treatment of the bone fractures of lower extremities with associated trauma allow timely identification of developing complications (syndrome of fatty embolism, deep vein thrombosis and thrombembolia of the pulmonary artery (PATE) and their modern treatment provided for preserving the life of the suffering. Keywords: multiple fractures, lower extremities, diagnosis, prevention, thrombembolia, ultrasound dopplerography.
Introduction
Traumatic injuries of the soft tissues and vessels, compelled extremity immobilization and a bed rest provide the most favorable conditions for occurrence of deep vein thrombosis and thrombem-bolic complications [2]. The statistical data testify to the frequency of deep vein thrombosis of the lower extremities accounts for about 160 on 100000 of population. The fractures of the long tube bones of the lower extremities are accompanied by the deep vein thrombosis of the lower extremities in 7,4% of cases [3].
The timely diagnosis of the deep vein thrombosis of the lower extremities is one of the leading tactics of the treatment of patients with multiple fractures of the bones of the lower extremities [4; 5].
The use of method of color Doppler mapping (CDM) provides possibility to differ quickly occlusive thrombosis from non-occlusive, to reveal the initial stage of thrombi recanalization, as well as to determine place of localization and size ofvenous collaterals [1; 6].
The purpose of the this stage of work was to study incidence rate of the deep vein thrombosis of the lower extremity in the patients with fractures of the long bones of the lower extremities with use of ultrasound duplex scanning (USDS).
Material and methods. We carried out the analysis of treatment of 120 patients bone fractures of the lower extremities who was performed ultrasound dopplerography of the lower extremities during the period from 2010 to 2014. Among the suffering patients there were prevailed males (91 -75,8%). The majority of patients (87,9%) were at the age of 31 to 60 years. The leading cause of the polytrauma were traffic accidents (89-74,2%).
The open fractures were found in 82 injuried patients (totally 112 fractures). According to classification of Caplan-Markova the fractures were distributed as follows: 27 fractures were related to the type IIB, 32 ones — to type IIV, 53 — to type IIIB. The closed fractures were in 38 patients.
The method of dopplerography was used in the hospital before and after surgery. The method of ultrasound dopplerography of the vessels of the lower extremities was performed at the mode of color mapping of the studied veins oflower extremities and dopple-rographic mapping of deep and superficial veins of the hip.
There were studied blood flow of the iliac vein (IVB), of the common femoral vein (CFV), big superficial vein (BSV), superficial femoral vein (SFV), popliteal vein (PV) and deep vena cava (DVC).
Results and discussion. According to the results of duplex scanning in the patients thrombosis of the vein before operation
was revealed in 33 (27,5%) patients. The signs of the postthrom-boflebitic disease were identified in 8 (6,7%) of patients.
At the analysis of the vein thrombosis during studied period there was noted twofold increase in occurrence from 12,1% in 2010 up to 24,2% in 2013 and 2014 (Fig. 1).
The carried out researches show the tendency to rising of identification of the patients with deep vein thrombosis (DVT) that, probably, may be connected with increase of quantity ofperformed ultrasound investigations of the deep vein of lower extremities.
In relation to a patency of the vessel the thrombi were differed as parietal, occlusive and floating. The signs of parietal thrombosis were visualization of the thrombus with presence of free blood flow in the vein patency, absence of complete wall adhesions in compression ofvein with transducer, presence of defect of filling at CDM, presence of spontaneous blood flow in ultrasound Doppler scanning.
At definition of a place ofthrombus localization there was found, that more than at half (19-57,6%) of patients the thrombosis was limited by the common femoral vein, in 7 (21,2%) patients there was defined in the iliac vein, in 3 (9,1%) the thrombosis was extended to the superficial femoral vein, in 2 (6,1%) thrombosis was in the area of great saphenous vein. The thrombosis of the popliteal (1-3,0%) vein and of the deep vein cava was found less often (1-3,0%).
With regard to character of the echogenic structures in the patency of vessels there were identified occlusive (48,5%), floating (33,3%) and parietal (18,2%) thrombi. Emboli dangerous thrombi with floating proximal part present threat for thrombembolia of the pulmonary artery (Table 1.).
The investigations were performed on the iliac vain, common femoral vein (FV), posterior and anterior tibial vein (PTV) (ATV). The results of ultrasound investigations were registered as photomaterial.
The diagnosis of thrombosis of the deep veins was confirmed in 22 patients. The thrombosis of the deep vein segments was revealed in 14 patients including ileofemoral segment — 4, femoro-popliteal-tibial segment — 4, cerebral vein segment — 6.
At revealing of DVT interfering to surgical treatment the conservative treatment was performed. Specific prevention was prescribed with direct anticoagulants. Administration of heparin in a doze 5000 UN every 8 hours (subcutaneously in the abdominal cavity) for 7-10 days (first injection 2 hours before operation), that reduces probability of the development of DVT and PATE approximately in 2 times.
Ultrasound diagnosis of the lower extremity deep vein thrombosis in the patients with multiple fractures of the bones.
Table 1. - The characteristic of the thromboses in relation to form and localization
Localization Thrombosis form Totally
Occlusive Non-occlusive
Floating Parietal
n % n % n % n %
Common femoral vein 10 30,3 7 21,2 2 6,1 19 57,6
Iliac vein 3 9,1 3 9,1 1 3,0 7 21,2
Superficial femoral vein 1 3,0 1 3,0 1 3,0 3 9,1
Great saphenous vein - - - - 2 6,1 2 6,1
Popliteal vein 1 3,0 - - - - 1 3,0
Deep vena cava 1 3,0 - - - - 1 3,0
Totally 16 48,5 11 33,3 6 18,2 33 100
It was more rationally to prescribe low-molecular heparins (LMH) fraxiparin, clexan which increased opportunities for prevention of TEO. Low molecular heparins are as effective as non-fractionated heparin, and as well as they have a number of significant advantages. LMH are differed by more prolonged effect, they may be injected 1 (2) times a day. Thus there is no necessity for the daily laboratory control, and the adverse effects and complications (including influence on functions of thrombocytes and hemorrhage) develop less often. The conservative treatment including application of anticoagulants, disaggregants, phlebotonics, elastic compression, bed rest and others were performed in 22 patients. The women suffer from this disease approximately 2 times more often than men.
At massive embolism of the vein from the system of low vena cava in the ileocaval segment taking into account of the big risk of the development of the PATE there was used Streptokinase 250 000300 000 MUN in the first 3-4 hours with use of doser with following administration of 100 000 ME with use of doser under the control of INR (international norm ratio) in norm from 0,85 to 1,15.
In 8 patients there were identified thrombi in relation to the patency ofvessel. They were differed as parietal, occlusive and floating thrombi.
The complete occlusion of the patency was revealed in 2 patients, parietal thrombi were visualized with presence of free blood flow in the vein patency, absence of complete adhesion of the walls in 4, floating thrombi in the common femoral vein in 2 patients. Not fixed (floating) part of the thrombus, according to the ultrasound data, varied from 2 to 8 cm. The moderate mobility of the thrombotic masses was found more often. The patients with thrombotic complications were performed the following surgeries:
- plication of the left common femoral vein with thromboec-tomy — 3;
- thrombectomy — 3;
- ligation of the major veins — 2.
The patient after the surgery was prescribed low molecular heparins (fraxiparin) subcutaneously instead of the traditional heparin. Then the patient was transferred to the receiving of the peroral anticoagulants.
Then the patient was transferred for receiving of peroral anticoagulants. Xarelto-rivoroxaban ZAO company "BAIER" was used in 10-12 hours after operation in dose 1 tablets (10 mg) 1 time a day after operation. Preparations were received during 2-3 months and more.
In dynamics for estimation of progress of the thrombotic process there were studied 20 patients, of them in 8 patients the partial recanalization of the thrombotic masses were noted. The restoration of the vein patency was registered in 12 cases.
Conclusion
1. The early diagnostic measures and complex persevering prevention of the thrombembolic complications, active timely revealing
of developing complications and their modern treatment are capable to save life of the injured victims.
2. Ultrasonic angio-scanning of the veins of lower extremities before and after operation and before discharge from hospital allowed timely to reveal developing without symptoms thrombosis of the deep veins in 91,5% of cases.
3. The transition at treatment and prevention of deep vein thrombosis from injection of low molecular anticoagulants (Fraxiparin, Clexan) to peroral tablets xarelto (rivoroxaban) is not less effective, more simple, safe and rational, than not fractionated heparin.
Clinical example
The patient Abduraimova O, woman of 52 year-old, received trauma due to traffic-incident. She admitted to the department with diagnosis: associated trauma. Brain injury, contusion of the soft tissues and bruise in the upper third of the left hip, bruise of soft tissues of the left knee joint, closed fracture of the middle third of the right humerus with displacement of the bone fragments. On the 7th day after trauma there were appeared edema of the legs, particularly in the area of the hip, ankle joint, increase in figures of the subcutaneous veins, light cyanosis of the skin integuments, tenderness along the vascular bundle. Ultrasound duplex angioscanning with color Doppler mapping allowed reliable diagnosis of the presence or absence of the thrombosis of lower extremities. At the dopplerography of the left lower extremity in the femoral vein there is determined thrombus with single point of the fixation in the distal part. The main its part is distributed freely along all the length and not connected with walls of the vein. The length of the floating part of the thrombus accounted more than 2 cm. In the are of the fixing site of the thrombus the occlusion was insignificant, floating part of the thrombus occupied almost all patency of the vein, blood flow is sharply reduced, the retrograde blood flow is determined. After consultation of angiosurgeon the patient was performed plication of the left common femoral vein with thromboectomy. The patient was performed complex medicamentous therapy, strong bed rest, rising position and elastic dressing of the extremity, including low molecular heparins (LMH), clexan and fraxiparin. Heparin was injected in dose 5000UN intravenously by bolus with further infusion with velocity 1000 UN in hour. The velocity of the administration was controlled in 6 hours after onset of infusion with purpose to rise it 1.5-2 times from the initial level. Reosorbilact 400.0 was injected intravenously, venotonics — detrolex, flebodin 600 1 tablet. There was made diagnosis: Acute thrombosis of the left common femoral vein, floating thrombus of the left common femoral vein.
The patient after operation instead of traditional heparin was prescribed low molecular heparins (fraxiparin), subcutaneously. In this case there is no necessity for the daily laboratory control, and the adverse effects and complications (including effect on the functions of thrombocytes and hemorrhages) developed less often.
The patient in dynamics for estimation of the development the veins of lower extremities.
of thrombotic process there was performed dopplerography of
References:
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5. Kopenkin S. S. Prevention of the venous thrombosis and pulmonary embolism in the orthopedics. Klinicheskaya farmakologia I terapia, - Moscow, - 2006, - N2: - P.38-42.
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Yugay Igor Aleksandrovich, Republican Scientific Centre of Neurosurgery.
Tashkent, Uzbekistan. E-mail: yia01@mail.ru Mamadjanova Risolat Abduvahabovna, Republican Scientific Centre of Neurosurgery.
Tashkent, Uzbekistan. E-mail: risolat-0409@mail.ru Akhmediev Makhmud Mansurovich, Republican Scientific Centre of Neurosurgery.
Tashkent, Uzbekistan. E-mail: mahmudneuro@mail.ru
The method of determination of intracranial pressure in patients with crania bifida associated with hydrocephalus
Abstract: here have been analyzed 35 children in Republican Scientific Center of Neurosurgery with encephalocele associated hydrocephalus. Patients were divided into 2 groups: Basic and control group. For the first group to choose correct parameters used program — "Ликвородинамический тест" (so called "CSF dynamics test"). This method enhanced to choose parameters accurately there by helping deal with postoperative shunting procedures complications. Keywords: encephalocele, hydrocephalus, intracranial pressure.
Introduction. Cranio-cerebral herniations (cranium bifi-dum) — congenital malformation occurs from 1: 4000-6000 to 1: 35,000 newborns and often has a poor prognosis for recovery [3, 22-25; 7, 39-42], especially at the location of craniocervical junction. Meningocele has better forecasts. Encephalocele can results in serious complications such as hydrocephalus. Encephalocele — frontal or occipital is the worst case of brain-skull herniation [9, 224]. The combination of encephalocele with hydrocephalus can be up to 30% of cases. This group of patients requires a landmark of surgical procedures [2, 40].
In modern literature research in hydrocephalus and other problems of intracranial pressure are used the concept of elasticity ofthe cranial system and its capacity [6, 25]. Carrying intracranial pressure correction from this position will also be considered to be justified also in cranial hernias. In addition, delayed primary operation — removing encephalocele in some cases may also be dictated by the somatic burdened child, poor physical development, early age [1, 40].
Surgical treatment of hydrocephalic syndrome carries out shunting operations using valve systems that are configured on dif-
ferent pressure [4, 29-32; 5, 153; 8, 15-26].
In our clinic, hydrocephalus shunt surgery demonstrations are held as the first stage ofthe treatment ofthese patients. Postoperatively, in some cases, there may be signs of inadequate correction of hydrocephalic syndrome that can be judged by the covers of encephalocele: maintaining its voltage and increase until its rupture, worsening of the neurological deficit, no increase of the surface epithelium in the her-nial sac, as well as the progressive growth of the skull circumference.
With this in mind, we have begun a study on the selection of adequate parameters of the shunt systems for patients with encephalocele, combined with hydrocephalus.
Stress tests which are used to determine the production of liquor rate in hydrocephalus patients are unacceptable in encephalocele since there is an increased risk of the hernia sac rupture [6, 25].
Additionally, elastic and capacitive characteristics of the ventricular system in these patients are radically different compared to patients with isolated hydrocephalus because of the presence of an additional capacitance — encephalocele sac, the dimensions of which may vary within wide limits and elasticity of an encephalocele
