A method of treating mine explosive wounds of the extremities of separation and crushing one, broken bones and other tissue defect

 

(57) Abstract:

The invention relates to medicine, namely to traumatology. Essence: in the reactive-toxic, toksemicheskim and infectious-toxic periods surgical intervention exercise, keeping a scrap of fabric end of the residual limb torn off or crushed segment limbs and turning them into the recovery period in proprietary autograft on two supply legs by cutting out at the end of the stump waste flap and sew its free end to the surface of the wound defect of the contralateral limb, and after 3.5 to 4.5 weeks perform a single step of reamputation one and plasticity of the wound defect other limbs vascularization and trained to ischemia with autograft from the waste material that prevents complications. 3 Il.

The invention relates to medicine, in particular to methods for treating mine blast injury (MW) of the extremities.

Due to MW on the human body are several damaging factors: direct shock action of the blast wave, the influence of the flame jet, sharp fluctuations in atmospheric pressure (barotrauma) and sound waves (ache a severe combined polytrauma with commotion-concussion syndrome, and when a contact of mine-explosive injury (IMM) separation and ruptured segment of one limb, severe fracture and extensive soft tissue defect - other, often observed simultaneously wound or closed damage other areas of the body.

There is a method of treatment of mine explosive wounds of the extremities of separation and crushing one, broken bones and other tissue defect described in the book edited by L. N. Lisenkova "Surgery mine and explosive wounds". - St. Petersburg, 1993, 320 C. For implementing the method produces primary amputation at the level of the upstream segment in the area of molecular concussion tissue, purulent-necrotic complications perform reamputation, repeated surgical debridement and plastic wound stump, and on the contralateral limb perform surgery as in the treatment of avoidant MW. However, using a known method of treatment for mine and explosive wound with a margin of tibia at the level of even its distal in connection with primary amputation at the hip level, the victim loses the knee joint, and disability is exacerbated. Almost half of the cases you reamputation although h the help of the wound defect contralateral limb requires donor sites, what is problematic in casualties with MW.

There is a method of surgical treatment of contact mine explosive wound with a margin of the limb segment, based on the results of fundamental clinical and experimental research, you can save the adjacent joint and segment of the affected limb (see pages 239-273 Nechaev E. A. , Gritsanov A. I., Fomin N. F., Minnullin I. P. Anatomical-physiological and experimental study of some methods of surgical treatment of the affected mine arms./In the book: Mine blast injury. - St. Petersburg. - 1994. S. ). The method provides for early and adequate infusion and transfusion therapy, normalization of systemic hemodynamics and microcirculation, powerful antibacterial therapy, complete drainage of the affected bone and fascial spaces, economical necrectomy based on the configuration of wounds and surgical anatomy vnutripochechnykh damage. Although this method has enabled to 81.7% of the wounded to perform an amputation within the destroyed segment of the limb to save the adjacent joint with wound healing predominantly primary tension, lack of plastic material required to eliminate renewal is REABILITACII wounded.

Closest to the proposed technical solution is a method of surgical treatment for a gunshot injury of the extremities, proposed by N. N. Sokinym and described in the book "the Amputation in military field conditions", Y. G. Shaposhnikov, N. N. Kukin, A. C. Grassroots. - M.: Medicine, 1980, 152 C. This method is as follows. After you prepare the wounded for surgery, typically handle the surgical field. In the beginning of the operation of the intact tissue at the site of the limb to be amputated, cut skin and fascial flap semi-oval shape. After separation of the flap from the underlying tissues, it turn up. Amputation is produced in the usual way, leaving the wound stump open. Flap two or three seams sew in the tubular stem and avoid excess is drained by a thin rubber tube, which serves at the same time and for the outflow discharge. Under the tubular stem enclose cotton-gauze swab, which holds the flap in the raised position. The wound stump impose aseptic bandage. In the case of a festering wound stump through the drainage injected antibiotics and washed the wound. A tubular graft to close the wound at different times depending on the nature of those who m defect and stitched to the skin edges of the wound stump-type primary-deferred seam.

However, the clinical application of the prototype revealed a number of drawbacks:

1) the method is used only in connection with a massive destruction of the bones, muscles and blood vessels in primary amputations of limbs in healthy tissues;

2) because the known method involves the performance of a primary amputation typical way within healthy tissue, using it is not possible for primary surgical treatment of wounds of the stump with a truncation at the injured tissues damaged segment of a limb due to high probability of necrosis of the flap;

3) using a known method can be carried out plastic skin and subcutaneous fascial flap on the supply leg only of the wound defect of the stump;

4) it is not always possible to avoid excess skin of the tube, and with it comes a rough circulatory disorders, necrosis of the flap;

5) cotton-gauze swab used to hold the flap in the raised position, is a "plug" for gunshot wounds, violates the outflow of wound, aeration of the wound, promoting the development of anaerobic infections;

6) because you are creating a skin and fascial flaps have to adapt to the level of imput is giving depend on the nature of the damage, localization gunshot wounds and other conditions, the application of the method becomes limited;

7) flap should only be created when there is sufficient confidence in his blood.

The objective of the proposed technical solution is early and effective medical rehabilitation of patients with contact mine and explosive wounds of the extremities, prevention of complications and consequences.

This problem is solved due to the fact that, in jet-toxic, toksemicheskim and infectious-toxic periods wound disease surgical intervention carried out keeping scrap fabric end of the residual limb torn off or crushed segment limbs and turning them into the recovery period in proprietary autograft on two supply legs by cutting out at the end of the stump waste flap sewing its free end to the surface of the wound defect of the contralateral limb, and after 3.5 to 4.5 weeks perform a single step of reamputation one and plasticity of the wound defect other limbs vascularization and trained to ischemia with autograft from scrap fabrics.

The implementation of the method can be viewed on arelatum bones and other tissue defect. In reactive-toxic period on a limb with a torn segment impose harness on the level of the adjacent segment (area of molecular concussion). After antishock measures typical amputation within healthy tissues do not produce, and under General anesthesia carry out primary surgical processing of wounds with truncated stump of a limb in the area of late secondary necrosis or at the level of the conventional boundaries between it and the area early secondary necrosis. When this scrap of fabric from the end of the stump is not cut off. After using the toilet neurovascular bundle on the lateral and medial surface of the end of the stump produce decompressive fasciotomy or testimony - myofascitis. The wound loose plugging wipes, impregnated with a water-soluble ointment. Put back a plaster of Paris splint is placed with fixation of the adjacent joint. On the contralateral limbs and other body parts available wounds subjected to usual primary surgical treatment, apply a bandage with a water-soluble ointments, carry out the immobilization bus Kramer, a plaster cast or external fixation device. In the period toxemia and infectious-toxic period MW continue intensive General and local pathogenetically. On the dressings daily exercise how agressively to debride, if necessary, repeat surgical treatment of wounds with intraosseous perfusion of the affected tissues, including the stump. When this scrap of fabric from the end of the stump is not cut off as well as for primary surgical treatment of wounds. Prior to the recovery period of traumatic disease of the wound impose multi-layer hydrophilic-hydrophobic dressings with multicomponent pharmaceutical composition, while providing a pronounced dehydration, nekroliticescoe, antibacterial and trophic effect (proteolytic enzymes, dissolved in 30% aqueous solution of urea, water-soluble ointment polyethyleneglycol, naftalina ointment). For early full plastic closure of the wound defect other limb in the early recovery period scrap fabric side of the stump to turn into proprietary autograft (skin, skin-subcutaneous, dermal and subcutaneous fascial and skin-muscle, muscle, bone, magadino-bone if necessary) to two supply legs. Depending on the nature and size of the tissue defect of the contralateral limb at the end of the stump from scrap fabrics cut out sooty. After surgical rehabilitation wounds on the surface of the wound defect contralateral limb, sew the free end of the flap, a cut on the side of the stump of the other limb, which simultaneously prevents retraction of the flap. Both limbs between a fixed plaster cast or external fixation device, while at the same time the osteosynthesis of bone fractures. Continue General and local treatment. After 3.5-4.5 a one-week exercise reamputation stump at an appropriate level in the damaged segment of the limb donor, plastic wound defect limb-recipient krovosnabzhayutsya already through the tissues of the limb-recipient waste autograft, trained to ischemia. In the postoperative period continued General and local treatment in the usual manner to wound healing and consolidation of fragments of bones. When using this method wounds usually heal by primary intention within the usual timeframes. One of the main advantages of the proposed method of treatment in comparison with the known technical solutions is that waste material stump, turning in krovosnabjaemah autograft, is trained to deep hypoxia in swasv transplant the transplant despite his bending, even at a sharp angle, macro - and microcirculatory disorders is not observed (see Fig. 2A and 26).

Clinical example. The victim A. , East. bol-no 745. As a result of blasting on antipersonnel mine 07.01.1997 year received contact mine blast injury (MBP). Two hours after the injury brought on stage a skilled surgical care with a diagnosis of severe combined contact ICBM with a margin of the right lower extremity at the level of the ankle joint, with shrapnel tearing of soft tissues prednimustine surface of the left ankle and left foot with a bared bones of the Tarsus, open comminuted fracture of the calcaneus and the talus bone of the left foot, shrapnel perineal defect tissues of the vulva, traumatic shock III degree, contusion. In reactive-toxic period ICBMs 3 hours after trauma in parallel with antishock measures produced by the primary surgical treatment of wounds of the lower extremities and perineum with wound closure of the urethra to drain the tube. Primary classic amputation of the right lower limb is not performed. Performed excision of primary necrotic tissue with truncation of the right tibia established segment run on medial and lateral side of the end face of the shank stump decompressive myofascitis.

In the period toxemia and early toxic period MBP was conducted intensive General and local treatment. After the relative stabilization of the General condition of the injured evacuated to the stage of the specialized surgical treatment.

Clinical and radiological diagnosis at admission - toxic contact period MBP: poorly-granulating wound amputation stump of the right tibia at the level of the border of the middle and distal diaphyseal segment; the soft tissue defect of prednimustine surface of the left ankle joint and the medial edge of the left foot with a bared bones of the Tarsus and purulent arthritis of the talus-navicular joint; open fracture of the calcaneus and the posterior process of the talus bone of the left foot; poorly-granulating wound with a tissue defect of the scrotum and the front surface of the external opening of the urethra. The overall condition is moderate, due to intoxication syndrome. Skin, pale tongue with whitish-gray bloom, a slight increase in peripheral lymph nodes. Blood pressure 110 70 mm RT.art., pulse 100-105 beats in 1 minute, satisfactory filling and voltage. From wnnaa ESR, the tendency to hypercoagulability.

Before the start of the recovery period, there was a common pathogenetic therapy. In the local treatment produced the surgical treatment of wounds, daily how agressively to debride tissue, leaving the waste of the tissues at the end of the stump of the right tibia. The wounds were overlapped multi-layer hydrophilic-hydrophobic dressings with multicomponent pharmaceutical composition, while providing a pronounced dehydration, nekroliticescoe, antibacterial and trophic effect (proteolytic enzymes, dissolved in 30% aqueous solution of urea, water-soluble ointment polyethyleneglycol, naftalina ointment).

The recovery period MBP came 5 weeks after injury. The wounds were cleansed from purulent-necrotic tissue and covered with granulation tissue, was arrested intoxication syndrome. In the area of the wound defect of the left ankle joint and the inner edge of the left foot has a fistula with purulent discharge due to osteoarthritis of the talus-navicular joint (see Fig. 1). On the right leg shows reamputation at the level of the middle third, and on the left lower extremity shows the surgical treatment of wounds with sanati is in tissues does not allow the plastic flaps from the surrounding wound tissue defect. Transplant-free split skin grafts or free skin flaps on the entire thickness is not shown because their melting due to poor blood supply and suppurative process in perceiving the bed. In addition, the wound defect in the ankle and foot are exposed to considerable mechanical stress, and therefore in the aftermath of 4-6 months there is a need for reconstructive surgery. Free flap transplantation overlay microvascular anastomosis requires microsurgical techniques, there is a risk of necrosis of the graft in connection with violation of hemodynamics in the victim in the early period of the MDBs. The implementation of the plastic flaps on the supply leg of the tissue close to the wound, is not possible due to the insufficiency of the resources of the tissues due to the large size of the wound defect. Traditional direct transplantation of a flap on the supply leg or plastic Filatov stem also not shown, because the victim in the recovery period ICBMs limbs with combined damage to the perineum may not be in an untenable situation for a long is routed solved scrap fabric (trained to ischemia in the MW) end of the stump right leg to turn in proprietary autograft on two supply legs by cutting out and sewing its free end to the wound surface of the contralateral limb, then after 3.5-4.5 a one-week run reamputation right Shin and plastic wound defect left lower extremity krovosnabjaemah waste flap.

Operation 13.02.1997, (after 37 days after injury): the surgical treatment of wounds, turning waste of skin and subcutaneous fascial flap end of the stump of the right tibia in the autograft on two supply legs; external neocolony osteosynthesis of fractures and fixation of extremities between an external fixation device.

When revising the wounds of the left ankle and left foot noted that under purulent granulations in the middle of the wound has purulent fistula which is connected with the talus-navicular joint. Around the fistula bones of the Tarsus bare, covered with purulent granulations. Made of surgical rehabilitation of purulent-necrotic lesion removal of nonviable tissue, washing the wound with antiseptic solutions, hemostasis.

From scrap fabrics formed after the alleged reamputation vicious stump right leg, formed of skin and subcutaneous fascial autograft on two supply legs by cutting out and sewing to ranawana apparatus, A. Ilizarov (see Fig. 2A and 2B). Wound on the surface of the superimposed hydrophilic-hydrophobic dressing.

In the postoperative period was carried out restorative and General treatment. Due to the fact that the skin is the subcutaneous fascial graft from scrap fabrics since mine blast injury until recovery period MBP've been trained to ischemia, signs of microcirculation disorders and other complications were noted. Wounds of the perineum healed by second intention.

The final stage of surgical treatment - surgery 11.03.1997, (in 27 days after the previous operation): reamputation stump of the right tibia of the middle Department of the diaphyseal segment of plastic wound defect region of the left ankle and left foot waste krovosnabjaemah skin and subcutaneous fascial an autograft, the remounting of the apparatus, A. Ilizarov on the left leg and foot.

With the stump of the right tibia dismantled the apparatus sneakerboy fixation and acute separated by skin and subcutaneous fascial graft, prejusa within 4 weeks of another supply leg to wound defect of the left lower extremity. Re-debridement and plastic wound defect left solenoidoperated, which is sewn along the edges of the wound atraumatic vertical seams. The remounting of the apparatus, A. Ilizarov fixation of the talus navicular joint of the left foot. One-step was reamputation and the formation of the full functionally advantageous stump of the right tibia at the level of the middle Department of the diaphyseal segment.

In the postoperative period, there was a General tonic and symptomatically therapy. Antibiotics are not applied. Topically used hydrophilic-hydrophobic dressings. The course of the wound process smooth. Purulent-necrotic, circulatory and any other complications were noted. Wound healing by primary intention (see Fig. 3). The stump of the right tibia prosthetic 85 days after receiving the contact MBP and apparatus sneakerboy fixation in connection with the consolidation of fragments of the bones of the foot lifted after 3 months. 10 days after injury. Moves freely without canes, shoes in the field of skin and subcutaneous fascial graft on the left foot, not worried. Discharged 21.04.1997, long-term results after 4 years. Relapse suppurative process, disease stump, ulceration of the transplant and any other complications were not. Walking without a cane no complaints. Job.

A method of treating mine explosive wounds of the extremities of separation and crushing one, broken bones and other tissue defect, comprising the step of surgical intervention for pathological lesions, characterized in that the reactive-toxic, toksemicheskim and infectious-toxic periods surgical intervention exercise, keeping a scrap of fabric end of the residual limb torn off or crushed segment limbs and turning them into the recovery period in proprietary autograft on two supply legs by cutting out at the end of the stump waste flap and sew its free end to the surface of the wound defect contralateral limb, and after 3.5 to 4.5 weeks perform a single step of reamputation one and plasticity of the wound defect other limbs vascularization and trained to ischemia with autograft from the waste material.

 

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