Актуальність. У значної частини хворих із застарілими травмами верхньої кінцівки актуальне хірургічне відновлення опозиції першого пальця. Мета: визначити ефективність оперативних втручань із відновлення протиставлення першого пальця кисті при наслідках травм верхньої кінцівки, окреслити основні фактори, що зумовлюють ступінь відновлення опозиції, і можливі причини незадовільних результатів. Матеріали та методи. 39 пацієнтам із застарілим пошкодженням периферичних нервів (19 хворих), плечового сплетення (11 пацієнтів) та ішемічною контрактурою верхньої кінцівки (9) виконували: опоненопластику (25) й опоненодез (14). Оцінювалась динаміка відновлення функції першого пальця й спроможність до трипальцевого захвату за його участю. Результати. Ефективність опоненопластики в більшості проаналізованих випадків була нижчою за очікувану, методики опоненопластики з використанням сухожилків згиначів (Tompson, Bunnell) були ефективніші за методики з використанням розгиначів. Проте вихідні умови дозволяють реалізувати ці методики лише в третини хворих, які потребують такого відновлення. Методики з використанням розгиначів пальців кисті (Taylor, Burkhalter) дають переконливий безпосередній результат, проте в післяопераційному періоді ефективність їх суттєво зменшується, що вимагає особливих підходів для її збільшення. Ефективність операції опоненодезу більш прогнозована, проте відновлення захватів потребує коректної функції довгих пальців кисті, а вибір позиції першого пальця — ретельного узгодження з пацієнтом. Висновки. Необхідне створення системного підходу для вибору методик і врахування компонентів виконання цих втручань. Окрім того, важлива оптимізація цих втручань за рахунок уточнення натягу сухожилка м’яза-двигуна і застосування засобів для зменшення адгезивного процесу.
Summary. Complex Regional Pain Syndrome Type I (CRPS I) (G90.5) is a set of condi- tions accompanied by regional pain that is disproportionate in time and degree relative to the normal course of the post-traumatic period or other lesion, does not correspond to the zones of innervation of certain nerves or nerve roots and is usually manifested by sensory, motor, vasomotor, and/or trophic disorders in distal extremities. A multidisciplinary consensus on the basic principles of diagnosis and treatment of complex regional pain syndrome type 1 was adopted at a round table meeting at the XVIII Congress of Orthope- dists Traumatologists of Ukraine in Ivano-Frankivsk on October 10, 2019.Principles of diagnosis and treatment:1) Individual approach taking into account the leading pathogenetic mechanisms of the disease.2) Control over the total number of appointments.3) Using the Bruehl, Atkins or Veldman criteria to diagnose CRPS I.The treatment influence the following links of the pathogenesis of the disease or indi- vidual symptoms: a) inflammation – DMSO (compresses), corticosteroids (short course), b) pain – gabapentin or pregabalin, in case of low effect – antidepressants (in case of no effect – pain treatment by using subanesthetic doses of ketamine, narcotic analge- sics, implantation of neurostimulants or pumps for intrathecal drug administration or sympathetic blocks); c) central nervous system training (mirror therapy, imaging and behavioral therapy, etc.); d) reduction of fear of movements and pain; e) anti-edema and venotonic agents; f) vitamin C; g) activation of the affected limb with increase in range of movements, muscle strength and load tolerance (immobilization only accord- ing to strict indications); с) transcutaneous electrical stimulation of the nerves, ultra high frequency (UHF) in impulse mode and oligothermal dose; i) surgical interventions - surgical treatment is indicated for CRPS type II; for CRPS type I it is indicated in cases where such treatment is intended to eliminate the trigger for CRPS development with adequate multimodal anesthesia/analgesia.
Summary. During the period of rapid industrialization, there was a need to create a new approaches to treat hand injuries due to rapid development of metallurgical, mining and engineer industry, which were accompanied by a high level of injuries with a significant amount of disability in the second half of 20th century, in Donetsk, Dnipropetrovsk and Kharkiv regions. New stage in the development of hand surgery and microsurgery in Ukraine began in the 80’s: the Department of Microsurgery and Reconstructive Surgery of the Upper Extremity under the direction of I. Antoniuk was opened on the basis of the SI “Institute of Traumatology and Orthopedics of NAMS of Ukraine” in Kyiv in 1982. Development of hand surgery in the western regions of Ukraine began in the 90’s. In Lviv, on the initiative of O. Toropovskyi, on the basis of the City Hospital No 8, a Center of Microsurgery and Surgery of the Hand was created. In Zakarpattia (Uzhhorod) since 1997, on the initiative of V. Haiovich and A. Pogoriliak, microsurgery and hand surgery service was established, which is now under the care of the Combustiology Department. In Volyn (Lutsk), hand surgery service is transmitted to the initiative group, also working at the City Combustiology Center. In Ivano-Frankivsk, Chernivtsi, Ternopil and Rivne, initiative groups in the field of hand surgery service have been formed in the structure of orthopedics and traumatology departments. 2005 was marked by the opening of another center for surgery of the hand in Luhansk on the initiative of V. Ivchenko and under the guidance of V. Golovchenko, whose surgeons owned microsurgical equipment and provided highly skilled assistance to the population of this region. Ukrainian Hand Surgery Society (UHSS) was created in 2012, and led by Professor S. Strafun, as a result of collaboration of all hand surgery centers. In 2014, UHSS was accepted into the Federation of European Societies for the Surgery of the Hand (FESSH).
Objective. To determine a role of «wide awake» аnesthesia for improvement of results of tendon–muscular transpositions on the hand. Маterials and methods. During 2016 – 2017 yrs a «wide awake» аnesthesia was applied in 32 patients, suffering consequences of the upper extremity and ageing 16 – 68 years. Median age of the patients have constituted (38.7 ± 14.7) years. Results. The results of a “local awake аnesthesia without placing a tourniquet” while performing a tendon–muscular transpositions and the mobilization operations on the hand were estimated. Conclusion. High efficacy of a «wide awake» аnesthesia in nonvolume function–creating interventions, performed with addition of sliding and active structures and necessitating close intraoperative cooperation with the patient, was proved.
Summary. Analysis of the restrictions in the amplitude of movements in the joints is traditionally considered from the standpoint of individual nosologies that cause them, but the systemic results of the inverse syndromological approach to the study of contractures are published only sporadically. Objective: to determine the structure, causes, nature, and severity of contractures of the upper extremity joints. Materials and Methods. The structure of contractures of the upper extremity joints as the consequences of injuries and diseases was analyzed on a large array of patients (16,710 patients). Distribution by location, etiology, severity of contracture, gender and age, and relationships between type and localization of contracture were assessed. The dynamics of the development of contractures and the number of necessary surgical interventions was traced. Results. Restriction of movements in the upper extremity joints was registered in 5,450 out of 16,710 (32.6%) patients; among them there were 3,485 male (63.9%) and 1,965 (36.1%) female patients. During reconstructive treatment, 7,892 surgeries were performed. Most often these were contractures of the finger joints (42.5%), then shoulder (26.9%), elbow (13.4%), carpal joint (13.3%), less often – radioulnar contractures (3.9%). The elbow, radioulnar and carpal joint contractures most often are caused by osteo-cartilaginous lesions; a polyetiological component is typical for the finger joints. The shoulder joint contractures may be caused evenly by desmogenic, myogenic, or osteo-cartilaginous lesions. Most of the joint contractures are of moderate severity. Contractures of the fingers require multi-stage surgical treatment (1.91±1.35 surgeries); one-stage treatment is used for contractures of the shoulder joint (1.34±0.81 surgeries). The most polystructural lesions were combat wounds, ischemic, and finger contractures (2.53±1.22; 2.52±1.34 and 2.5±1.24 structures, respectively), and the least – radioulnar contractures (1.59±1.34 structures). Radioulnar contractures in 37.3% of cases are accompanied by contractures of the fingers, but vice versa only in 1.2%. It was noted that contractures of the radioulnar joints are often accompanied by restriction of movements in the elbow and wrist joints – in 34.9 and 56.6% of cases, respectively. At the same time, the inverse dependence of the combination of contractures in the wrist and elbow joints with radioulnar joints is not very high – 4.2% and 6% of cases, respectively. Conclusions. In patients who are hospitalized for highly specialized surgical treatment of pathology of the upper extremity, contractures of its joints are moderate and severe, characterized by polyetiology, and, in most cases, caused by disorders of osteo-cartilaginous structures and their combination with desmogenic, tenogenic, and myogenic lesions. Specific relationships are traced in localization and mutual burden of contractures, rapidity of their progression. As a rule, upper limb contractures are chronic ones and require multi-stage surgical treatment.
Summary. According to the literature, the pathogenesis of the secondary carpal tunnel syndrome in distal radius fractures remains poorly studied; local post-traumatic compartment syndrome is one of the possible mechanisms of its development. Objective: to study the indicators of subfascial pressure in the carpal tunnel in fractures of the distal radius in the acute period of injury and their relationship with the severity of the fracture, skialogic indicators of displacement, the severity of pain syndrome, the patient's age, and time since the injury. Materials and Methods. The study included 24 patients with acute fractures aged 48.4±19.0 years, among them 8 males and 16 females. The time from the moment of injury to the measurement of pressure with the “Stryker monitor pressure system” device was 10.5±9.8 hours; the indicators were correlated with pain syndrome according to the VAS scale, skialogic indicators of distal epimetaphysis deformity, and the severity of fractures according to the classification of fractures of the Association of Osteosynthesis (AO). By interviewing patients in a long-term period, the complaints which are a characteristic of lesions of the median nerve at the level of the carpal canal were determined. Results. In distal radius fractures in the acute period of injury, the level of subfascial pressure is on average 26.5±12.3 mm Hg; however, more than a third of patients (37.5%) reach critical values, 30 mm Hg and more, which can lead to ischemic damage to the soft tissues of the hand, including the median nerve. A moderate reliable relationship between the subfascial pressure parameters in the carpal canal and the severity of the fracture according to the AO classification, the level of pain syndrome according to the VAS scale, the age of patients, and a weak probable relationship with the period after injury, the degree of relative shortening of the radius, indicators of intra-articular displacement and loss of ulnar inclination of the distal epimetaphysis were determined. No significant and reliable correlation between the indicators of intra-tissue pressure in the carpal tunnel and the angle of the palmar inclination of the articular facet in distal epimetaphysis of the radial bone fractures was found. None of the examined patients developed carpal tunnel syndrome, so there is no direct correlation between increased subfascial carpal tunnel pressure in the acute period after the injury and the incidence of median nerve compression neuropathy. Conclusions. A moderate reliable relationship between the subfascial pressure parameters in the carpal canal and the severity of the fracture according to the AO classification, the level of pain syndrome according to the VAS scale, and the age of the patients, as well as a weak reliable correlation with the post-injury period, the degree of post-traumatic deformity of distal epimetaphysis of the radial bone in the form of its relative shortening and loss of inclination, and indicators of intra-articular displacement were determined. In this study, no correlation was found between increased subfascial pressure in the carpal canal in the acute period after trauma and the occurrence of compression neuropathy of the median nerve.
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