Stable and functional osteosynthesis of the diaphyses of long bones of the lower extremities - errors and complications. Removal of metal structures after osteosynthesis of the femur

05.11.2019 -

According to forensic research on medical documents the specialist comes to the following medical conclusion: a number of shortcomings were made in the provision of medical care, which led to a slowdown in the consolidation of the fracture and chronification of the process. Therefore, in this situation there is a direct cause-and-effect relationship with the deterioration of the patient’s condition and the extension of treatment.

EXPERT'S OPINION

(based on forensic examination of documentation)

No. ____/20______

Based on the agreement …………….. on conducting a forensic medical study, a doctor, a specialist in the field of forensic medicine of the Regional Medical and Legal Center, with a higher education medical education, who completed clinical residency in surgery, specialization in forensic medicine, is a candidate of medical sciences, with over 15 years of work experience, carried out a forensic medical examination of documentation addressed to

Full name, 19** year of birth

The study began on June 27, 2014.

The study was completed on July 8, 2014.

The following questions were asked to resolve the study:

Are there any shortcomings in the provision of medical care by specialists of the Yamalo-Nenets Autonomous Okrug “N***kaya central” city Hospital» Full name, year of birth 19** and how are they expressed?
Is there a cause-and-effect relationship between the shortcomings of treatment, the provision/failure to provide medical care by the specialists of the Yamal-Nenets Autonomous Okrug "N***kaya Central City Hospital" and the deterioration of the patient's condition and the prolongation of treatment?

The specialist is provided with:

1. A copy of the discharge summary from the medical history No. *** GBUZ Yamalo-Nenets Autonomous Okrug "N*** Central City Hospital" dated "**" month 2013 addressed to full name, 19** year of birth;

2. A copy of the discharge summary from the medical history No. *** GBUZ Yamalo-Nenets Autonomous Okrug “N*** Central City Hospital” addressed to full name, born 19**;

3. A copy of the discharge summary of the medical record of inpatient No. *** from City Clinical Hospital No. ** named after *** of Moscow addressed to the full name;

4. Copy of the Discharge Summary Outpatient card No.** addressed to full name, 19** year of birth, dated “**” month 2013;

5. A copy of the Expert Opinion (protocol for assessing the quality of medical care) CK OJSC “***” addressed to full name, year of birth 19**;

6. Copy of the X-ray report humerus Regional Clinical Consultative and Diagnostic Center, ***, from “**” month 2014;

7. X-rays(14 pcs.) addressed to full name.

List of used literature:

1. Order of the Ministry of Health and social development RF dated April 24, 2008 No. 194n “On approval of Medical criteria for determining the severity of harm caused to human health”;

2. Surgical dentistry and maxillofacial surgery. National leadership./ Ed. A.A. Kulakova, T.G. Robustova, A.I. Nerobeeva // M. - GEOTRAR-Media - 2010;

3. Traumatology: national guide / ed. G.P. Kotelnikova,

S.P. Mironov. - M.: GEOTAR-Media, 2008.

STUDY

From the discharge summary from the medical history No. *** dated “**” month 2013 addressed to full name, born 19**, it follows: “Diagnosis: Severe combined injury. CCI. Brain contusion mild degree. Linear fracture of the frontal bone. Open fracture anterior wall of the frontal sinus on the left. Hemosinusitis. Fracture of the nasal bone. Multiple scalp wounds of the head and neck. Closed injury chest. Closed bilateral tension pneumothorax. Closed comminuted fracture of the upper third of the right shoulder with displacement of fragments. Closed iliac dislocation of the left hip. Fracture of the roof of the acetabulum on the left with mixed fragments. Bruised left knee joint. Traumatic, hemorrhagic shock, stage III.

Fracture of the lower jaw on the right in the area of the corner with displacement of fragments. Condition after osteosynthesis from “**” month 2013, fracture of metal structure, secondary displacement.

She was treated in the traumatology department from “**” month 2013 to “**” month 2013. She was admitted to the Yamalo-Nenets Autonomous Okrug National Central Hospital “**” month 2013. Upon admission, she was hospitalized in the ARO department. She was in ARO from “**” month 2013. by “**” month 2013, “**” month 2013 transferred to the traumatology department.

“**” month of 2013 Transferred to HO No. **, “**” month of 2013 again transferred to the traumatology department.

An. morbi: Emergency hospitalization. Delivered by CMII team. Road injury

"**" month 13 According to the EMS team, she was removed from the passenger car.

In the emergency department she was examined by a surgeon and neurosurgeon. OAK was taken and blood group was determined.

Taken bio. environment to determine the presence of alcohol. Due to vital signs, she was urgently taken to the operating room.

Operation “**” month 2013:

3. "Laparocentesis".

4. “Bilateral thoracentesis, drainage of the left and right pleural cavities according to Belau."

After the operation, a CT scan of the head and chest organs was performed. “**” month 2013 tracheostomy was performed.

Operation “**” month 2013:

Upon stabilization of the patient’s condition, “**” month 2013, the patient was transferred to the trauma department. She was consulted by a neurologist and treatment was prescribed.

“**” month 2013: pain appeared, pathological mobility in the area of the angle of the lower jaw on the right. A control R-graph of the lower jaw on the right was performed, a fatigue fracture of the titanium plate was detected. In agreement with the maxillofacial surgeon ***, the patient was transferred to the II surgical department for further treatment.

Operation “**” month 2013:

1. “Removal of metal structures, reosteositis of mandibular fragments.” “**” month 2013, the patient was again transferred to the trauma department. The maxillofacial area was examined several times. Recommendations are given.

“**” month 2013, the patient was consulted by professor, head. dept. Maxillofacial surgery of the Russian Research Center of Surgery, Moscow ***.

"**" month 2013 Skeletal traction for the epicondyles of the left thigh was removed. Clinically: the contours of the left hip joint are clear, the skin over the joint is not changed. On palpation, the load on the trochanteric area is painless, the “open book” symptom is negative. Range of movements in the left hip joint

close to complete, at extreme points moderately painful. There are no vascular or neurological disorders in the distal parts of the left lower limb. “**” month 2013 R-control of the lower jaw in 3 projections: the lower jaw is fixed with metal miniplates with screws in the correct position on the right...

1. Observation and treatment by a neurologist for left-sided hemiparesis facial nerve.

2. Treatment of the oral cavity with antiseptic solutions.

3. Observation by a dental surgeon once a week

4. Constantly wearing an elastic bandage

5. Removal of the rubber rod no earlier than “**” month 2013.

6. Removal of the splints in the absence of pathological mobility of the upper jaw a week after removing the traction.

7. Attendance at an appointment with a maxillofacial surgeon “**” month 2013

8. Attendance at an appointment with a traumatologist “**” month 2013

9. B/l 060468442921 from “**” month 201 to “**” month 2013; from “**” month 2013 to “**” month 2013.

Date of the VC “**” month 2013.”

On the radiographs presented for this study in the name of the full name, the following is determined. “**” month 2013 – displaced fracture of the right corner of the lower jaw. “**” month 2013 – comminuted fracture of the upper third of the humerus with displacement. “**” month 2013 – rupture of the fixing metal structure on the lower jaw, non-united fracture.

From the Discharge Epicrisis from the medical history No. *** GBUZ Yamalo-Nenets Autonomous District “N*** Central City Hospital” addressed to full name, year of birth 19**, it follows: “Diagnosis: Closed comminuted, non-united, fracture of the upper-middle third of the right shoulder with a mixture of fragments. Closed iliac dislocation of the left hip. Fracture of the plate of the middle third of the right shoulder, pseudarthrosis of the middle third of the right shoulder. On inpatient treatment in the trauma department from “**” month 2013 to “**” month 2013.

An. mor by: Domestic road traffic injury “**” month 2013 DZ: “Severe combined trauma, head injury, mild brain contusion. Linear merome of the frontal bone. Open fracture of the anterior wall of the frontal sinus on the left. Hemosinusitis. Fracture of the nasal bone. Multiple scalped wounds of the head and neck. Closed chest injury. Closed left-sided tension pneumothorax. Closed comminuted fracture of the upper third of the right shoulder with mixed closed iliac dislocation of the left hip Fracture of the roof of the acetabulum with displacement of fragments. Bruise of the left knee joint. Traumatic, hemorrhagic shock, stage III. Due to vital indications, she was urgently taken to the operating room for PSO of the wounds and drainage of the pleural cavities by the surgical team on duty. After the operation, a CT scan of the head and chest organs was performed. On a ventilator. “**” month 2013 tracheostomy. “**” month 2013 operation performed: “1. Osteosynthesis of a fracture of the lower jaw on the right in the area of the corner. 2) Osteosynthesis of the right humerus with the AO plate.” Upon stabilization of the condition “**” in the month of 2013, the patient was transferred to the trauma department. In the future - on outpatient treatment with a traumatologist with “**” month 2013. I applied for an appointment with a traumatologist “**” month 2013. with complaints of deformation in the area of the right shoulder. Sent to the trauma department. “**” month of 2013, the operation “Removal of a plate from the right shoulder, PCDO of the right shoulder” was performed. PCDO of the right shoulder using the Ilizarov apparatus.” In the department: symptomatic therapy, dressings, stitches were removed on the 10th day. Healing by primary intention. Discharged from the department for further treatment at the place of residence...

1. Fixation in app. Ilizarov until the fracture healed.

2. R-control of the right shoulder after 1-1.5 months. after surgery.

3. Outpatient treatment by a traumatologist, maxillofacial surgery.

4. Examination by a neurologist over time for the purpose of treatment correction.

...Date of the next VC “**” month 2013. Attendance at an appointment with a traumatologist at the place of residence “**” month 2013.”

On the radiographs presented for this study for the name Last Name First Name Patronymic, the following is determined. “**” month 2013 – destruction of the plate in the area of the fracture of the right humerus, angular displacement of fragments of the humerus: the angle of the fracture is open outward. "**" month 2013 – AVF (external fixation device) – insufficient reposition, angular displacement, separate fragment.

From the Discharge Summary of the Medical Record of Inpatient No. *** from City Clinical Hospital No. ** named after. *** Moscow follows: “Patient “**” month Age: 3* years. I was at station. treatment in 30 department. maxillofacial surgery City Clinical Hospital No. ** from “**” month 2013 to “**” month 2013

Diagnosis upon admission: Traumatic osteomyelitis of the lower jaw on the right. Incorrectly consolidated fracture of the lower jaw in the area of the angle on the right. Paresis of 2-3 branches of the facialis on the right. Slow consolidation fracture of the right shoulder. Condition after MOS with UKDO apparatus.

Diagnosis at discharge: Traumatic osteomyelitis of the lower jaw on the right. Incorrectly consolidated fracture of the lower jaw in the area of the angle on the right. Paresis of 2-3 branches of the facialis on the right. Slow consolidation fracture of the right shoulder. Condition after MOS with UKDO apparatus.

Complaints: pain in the lower jaw on the right when chewing, mobility of fragments of the lower jaw

Anamnesis (According to the patient): injury at home in an accident from the “**” month of 2013 in the city ***. A patient with a severe concomitant injury was treated in the ICU; osteosynthesis of the lower jaw on the right was performed, but the mobility of the lower jaw and pain when moving the lower jaw remained constant. Condition on admission: satisfactory. The configuration of the face has been changed due to paresis of the facial muscles of the right half of the face. There is a bluish scar about 20 cm long, bordering the edge of the lower jaw. Mouth opening is moderately limited to 3 cm, movements of the lower jaw are not significantly limited. On palpation, the symptom of load on the lower jaw is negative; pronounced mobility of the lower jaw is determined in the area of the angle on the right. The scar in the retromalar area on the right reveals redness of the mucous membrane, palpation is painful. There is no fistula tract. The bite is not affected. Condition at discharge: Satisfactory. The asymmetry of the face is changed due to swelling of the soft tissues of the lower jaw on the right, paresis of the facial muscles of the right half of the face. There is a bluish scar, about 20 cm long, bordering the edge of the lower jaw. The postoperative wound healed by primary intention, the sutures were removed. Mouth opening is moderately limited to 3.5 cm, swallowing is painless. The bite is not affected. No inflammatory or infiltrative changes were detected. Treatment was carried out in accordance with Moscow city standards of inpatient medical care.

Standard code 073.160 Code according to ICD M 86.1 28 k/day

Produced: “**” month 2013 osteosynthesis of the lower jaw with a reconstructive plate. Antibacterial therapy (doxycycline 1 x 2 times a day, ciprofloxacin 100 x 2 times a day), symptomatic therapy (local cold, diclofenac 3.0 for pain), infusion therapy, vitamin therapy, nootropic therapy. Physiotherapy was carried out...

X-ray of the chest organs: no focal or infiltrative changes were detected.

X-ray after osteosynthesis: The position of the bone fragments is satisfactory.

X-ray of the right humerus: fracture of the middle third of the diaphysis, condition after metal osteosynthesis. Consultation with a neurologist: neuropathy of the facial nerve.

Examination by a traumatologist: Slowly consolidating fracture of the right shoulder. Condition after MOS with UKDO apparatus. Recommended: exercise therapy, x-ray control after 6 months...

The hospital stage of treatment is completed, he is discharged with improvement, there is no threat to life, under the supervision of a dental surgeon at his place of residence. Appearance at the clinic “**” month 2013.

1. Observation by a dental surgeon at a local clinic.

2. Oral hygiene

3. Strictly gentle diet

4. Multivitamins (Complivit 1 t x 2 times a day for 3 weeks)

5. Calcium preparations (Ca DZ nycomed 1 t x 2 times a day for 3 weeks)

6. Milgamma 1t x 1 time per day.

Central City Hospital *** from “**” month 2013 – displaced fracture of the right angle of the lower jaw.

On the radiographs presented for this study in the name of the full name, the following is determined. “**” month 2013 – unstable fixing metal structure of the lower jaw, reposition is incomplete, the fracture line is gaping. In 2 pictures “**” month 2013 (frontal and lateral projection) – a plate on the lower jaw on the right, complete reposition. “**” month 2013 – AVF – good reduction, the axis of the humerus is almost not broken. “**” month 2013 – AVF – there is reduction, the axis of the humerus is almost not broken. “**” month 2013 – the fracture line is not determined, unexpressed bone callus, symptoms of osteoporosis.

From the Discharge Summary of Outpatient Card No.** addressed to full name, year of birth 19**, from “**” month 2013 it follows: “Diagnosis: Severe combined injury. CCI. Light contusion of the brain Linear fracture of the frontal bone. Open fracture of the anterior wall of the frontal sinus on the left. Hemosinusitis. Fracture of the nasal bone. Multiple scalp wounds of the head and neck. Closed chest injury. Closed bilateral tension pneumothorax. Closed comminuted fracture of the upper third of the right shoulder with mixed fragments. Closed iliac dislocation of the left hip. Fracture of the roof of the acetabulum on the left with mixed fragments. Bruise of the left knee joint. Traumatic, hemorrhagic shock, stage III.

Fracture of the lower jaw on the right in the area of the corner with mixing of fragments. Condition after osteosynthesis from “**” month 2013, fracture of metal structure, secondary displacement.

She was treated in the traumatology department from “**” month 2013 to “**” month 2013. She was admitted to the Yamalo-Nenets Autonomous Okrug National Central Hospital “**” month 2013. Upon admission, she was hospitalized in the ARO department, she was in the ARO from “**” month 2013 to “**” month 2013, “**” month 2013 transferred to the traumatology department. “**” month of 2013 transferred to HO No.**, “**” month of 2013 transferred again to the traumatology department

Anamnes morbi: Emergency hospitalization. Delivered by the EMS team. Road injury “**” month 2013. According to the media team, extracted from a car.

In the emergency department she was examined by a surgeon and neurosurgeon. Taken by OAK. determination of blood group. Taken bio. environment to determine the presence of alcohol. Due to vital signs, she was urgently taken to the operating room. Operations "**" month 2013:

1. “Post-surgical treatment of facial wounds, stitches were applied.”

2. “Reduction of the dislocation of the left hip, application of a skeletal traction system for the femoral condyles.”

3. "Laparocentesis".

4. “Bilateral thoracentesis, drainage of the left and right pleural cavities according to Bulau.”

After the operation, a CT scan of the head and chest organs was performed. “**” month 2013 tracheostomy was performed.

Operation "**" month 2013:

1. “Osteosynthesis of a fracture of the lower jaw on the right in the area of the corner. Splinting."

2. “Osteosynthesis of the right humerus with the AO plate.”

Upon stabilization of the patient’s condition, “**” month 2013, the patient was transferred to the trauma department. She was consulted by a neurologist and treatment was prescribed. “**” month of 2013, pain and pathological mobility appeared in the area of the angle of the lower jaw on the right. A control R-graph of the lower jaw on the right was performed, and a fatigue fracture of the titanium plate was detected. In agreement with the maxillofacial surgeon ***, the patient was transferred to the II surgical department for further treatment.

Operation "**" month 2013:

1. “Removal of metal structures, reosteositis of mandibular fragments.”

“**” month 2013 the patient was again transferred to the trauma department. The maxillofacial area was examined several times. Recommendations are given.

“**” month 2013 the patient was consulted by professor, head. dept. Maxillofacial surgery of the Russian Scientific Center for Surgery in Moscow ***. Recommendations are given.

“**” month 2013. Skeletal traction for the epicondyles of the left thigh was dismantled. Clinically: the contours of the left hip joint are clear, the skin over the joint is not changed. On palpation, the load on the trochanteric area is painless, the “open book” symptom is negative. The range of motion in the left hip joint is close to full, at the extreme points it is moderately painful. There are no vascular or neurological disorders in the distal parts of the left lower limb.

“**” month 2013 R-control of the lower jaw in 3 projections: the lower jaw is fixed with metal miniplates with screws in the correct position on the right. In the future, outpatient treatment with a traumatologist. From the “**” month of 2013 to the “**” month of 2013, she was hospitalized in the trauma department of the State Budgetary Institution of the Yamal-Nenets Autonomous Okrug of the National Central Clinical Hospital with DZ: Consolidating comminuted fracture of the middle 3rd right shoulder. Condition after MOS plate. Fracture of the plate, where “**” in the month of 2013 the operation was performed: “Removal of the plate of the right shoulder. PCDO of the right humerus according to Ilizarov with simultaneous intraoperative compression of fragments.” Subsequently, he received outpatient treatment from a traumatologist. The next stage of distraction-compression was expected 1 month after surgical treatment based on the results of control P-grams. but the patient voluntarily left the city of Novy Urengoy and sought medical help at City Clinical Hospital No. ** in Moscow (inpatient treatment from “**” month 2013 to “**” month 2013), where this was done (see. extract). Monthly - R-control of the right humerus. "**" month 2013 during the functional test While consolidating the fracture of the right humerus, pain appeared in the area of the middle third of the right humerus. The device is stabilized.

1. Observation and treatment by a traumatologist, neurologist regarding the left-sided facial nerve.

2. Dismantling the app. Ilizrov on consolidation of a fracture of the right humerus."

From the Expert Opinion on Assessing the Quality of Medical Care of the Medical Card Stat.

patient No. *** (Yamalo-Nenets Autonomous Okrug “N*** Central City Hospital”) CK JSC “***” should:

“...Resuscitation department from “**” month 2013 to “**” month 2013, 13 k/d.

Department of Traumatology from “**” month 2013 to “**” month 2013, 7 k/d.

Department II surgical from “**” month 2013 to “**” month 2013, 3 k/d.

Department of Traumatology from “**” month 2013 to “**” month 2013, 7 k/d.

...Operations

1. Osteosynthesis of the lower jaw “**” month 2013

2 Osteosynthesis of the shoulder on the right “**” month 2013

3. Removal of metal, reosteosynthesis of the lower jaw. "**" month 2013

Final clinical diagnosis:

Severe combined injury. CCI. Mild brain contusion. Linear fracture of the frontal bone. Open fracture of the anterior wall of the frontal sinus. Hemosinusitis. Fracture of the nasal bone. Multiple scalp wounds of the head and neck. Closed chest injury. Closed tension pneumothorax. Closed comminuted fracture of the upper third of the right shoulder with displacement of fragments. Closed iliac dislocation of the left hip. Fracture of the roof and acetabulum on the left with displacement of fragments. Bruise of the right knee joint. Traumatic, hemorrhagic shock III degree. Fracture of the lower jaw on the right in the area of the corner. Condition after metal osteosynthesis from “**” month 2013, fracture of the metal structure, secondary displacement...

During the examination of medical history No. *** (I3 ***), the following defects were discovered:

I COLLECTION OF INFORMATION (questioning, physical examination, laboratory and instrumental studies, specialist consultations, consultation);

Voluntary informed consent with the general plan of examination and treatment is not signed by the patient and the doctor; if this is not possible, there must be a note in the medical history and a message to the chief physician. Consultation with a maxillofacial surgeon on the 5th day. There is no description of radiographs of the skull and lower jaw upon admission. In the description of the radiograph of the lower jaw dated “**” month 2013, there is no description of the nature of the fracture or the position of the fragments. An examination by a neurologist was carried out on day 21. At the beginning of the medical history there is a note from a neurosurgeon without the date and time of examination. The record does not contain complaints, injury history, examination data or neurological status, only a brief diagnosis and no recommendations for additional examination and treatment. Consultations with a maxillofacial surgeon were carried out on the 5th day. Voluntary informed consents for operations “**” month 2013 No. There is no description of the skull radiograph and the primary radiograph of the mandible. An examination by a neurologist was carried out on the 22nd day from the moment of admission.

Justifications for the negative consequences of errors in information collection:

1. The patient’s rights to receive information about the condition and treatment provided are violated.

2. Consultations with specialists were carried out untimely.

3. There are no descriptions of some of the radiographs by the radiologist; some are described poorly.

II. DIAGNOSIS (wording, content, time of presentation)

The main diagnosis was formulated correctly, but the fracture of the 3rd and 4th ribs on the right was not sustained (x-ray from “**” month 2013), neuritis of the facial nerve. In addition, a fracture of the frontal bone, a fracture of the frontal sinus, hemosinusitis, and a nasal fracture are not confirmed by the descriptions of radiographs available in the medical history and consultation with an otorhinolaryngologist. Closed tension pneumothorax is not confirmed: upon admission, respiratory rate is 22 per minute, breathing is uniformly weakened. There is no radiological evidence for tension pneumothorax. When describing thoracentesis, the signs of tension pneumothorax are not described...

Justification of the negative consequences of errors in diagnosis:

The diagnosis reflects damage, some of which is not confirmed in the medical history, while another part of the damage is not included in the diagnosis.

III. TREATMENT (surgical, including obstetric care, medication, other types and methods of treatment) The protocols for the administration of PPS and AS do not indicate the series of drugs and expiration dates.

Operations: PSO of wounds, drainage of pleural cavities, laparocentesis, tracheostomy are not included on the title page, there is no voluntary informed consent for their performance, there is no explanation for this in the medical history. During PSO of facial wounds, a thorough inspection was not carried out and a fracture of the lower jaw was not detected. Tracheostomy was performed on day 3 without any reason. The indications determined by the doctor: lack of adequate breathing, the need for mechanical ventilation, the need for sanitation of the TBD are not such, because the presence of an endotracheal tube solves these problems. The operation protocols for the “**” month of 2013 do not indicate the duration of operations and blood loss. It is not possible to establish the time of fracture of the plate on the lower jaw because the patient states that this happened in the “**” month of 2013, but the medical history in the diary from the “**” month of 2013 contains no information about this. The next doctor's note is only "**" month 2013 without time. The patient experienced a complication of the operation - a fracture of the fixing plate on the lower jaw, which required reoperation. It can be assumed that the plate was defective, otherwise it is impossible to explain its fracture on the 9th day in an inactive patient. No drugs were used to stimulate fracture healing. FTL. Exercise therapy, massage.

Rationale negative consequences errors in treatment:

Defects in emergency tetanus prophylaxis. Performing a tracheostomy without sufficient grounds. The occurrence of complications after osteosynthesis of the lower jaw and the need for reoperation. No drugs were used to stimulate fusion, physical therapy, exercise therapy, massage...

IV. CONTINUITY (reasonableness of admission, duration of treatment, translation of the content of recommendations)

The first stage epicrisis from “**” month 2013, after 30 days of treatment. There are no transfer reports for transfers from the intensive care unit to the trauma department (presumably “**” month of 2013) and from the second hospital to the trauma department (presumably “**” month of 2013)

CONCLUSION of an expert on the quality of medical care;

When providing medical care Last Name First Name Patronymic errors were made corresponding to codes 3.2.1, 3.2.3, 4.2, 4.3.

The determining code is 3.2.3 - the occurrence of a complication after osteosynthesis of the lower jaw, which led to a deterioration in the patient’s condition and an extension of the treatment period.

THE MOST SIGNIFICANT ERRORS THAT AFFECTED THE OUTCOME OF THE DISEASE:

1. Absence in the medical history of data confirming part of the diagnosis and preventing the examination.

2. The occurrence of a complication after osteosynthesis of the lower jaw, which led to a deterioration in the patient’s condition and an extension of the treatment period.”

From the Interim Epicrisis of the Medical Record of an Inpatient No. *** MLPU “K*** City Hospital No. 1” Last Name First Name Patronymic follows: “I was inpatient treatment since the “**” month of 2013. Until now.

Diagnosis: Closed repeated fracture of the middle third of the right humerus with displacement of fragments, a consequence of severe combined polytrauma, traumatic brain injury, fracture of the facial skeleton, closed injury chest, closed fracture of the right humerus with subsequent refracture and repeated osteosynthesis, fracture of the acetabulum and dislocation of the left hip. Associated: Arterial hypertension 2st. 3st. risk 3 chronic gastroduodeitis without exacerbation. Angiopathy of the retina of both eyes.

Complaints: pain in the right shoulder, dysfunction. Anamnesis morbi:

According to the victim “**” month 2013 injury in an accident. Treatment in the N*** hospital for a combined injury: fracture of the shoulder, dislocation of the hip and fracture of the posterior edge of the acetabulum, UGM, fracture of the upper and lower jaw, complicated chest injury. Performed: osteosynthesis of the shoulder and jaw. In the early postoperative period Facial nerve paresis was detected. Subsequently, during rehabilitation, a fracture of the humeral and jaw plate with repeated synthesis in one of the clinics in Moscow. Synthesis of the jaw and humerus of the ANF was performed. In the “**” month of 2013, removal of the ANF and subsequent plaster casting (sleeve). On the day of admission, in the morning, while performing gymnastics, a shoulder fracture occurred.

At the time of examination, the general condition is closer to satisfactory, the skin has a physiological color. Heart sounds are muffled and rhythmic. PS - 84 per minute, BP - 130/80 mm Hg. Art.

Locally:

The shoulder is immobilized with a plastic bandage sleeve. The bandage has been removed, the shoulder is not swollen, there are no signs of inflammation, there are no neurotrophic disorders in the distal parts of the limb, pathological mobility and crepitus in the third shoulder.

Radiographs show a transverse fracture of the middle third of the humerus with displacement.

Control radiographs of the shoulder on the right show signs of the formation of a periosteal callus.

Treatment carried out:

Analgesics, sedative, decongestant therapy. Locally at the time of inspection:

The swelling of the shoulder is moderate, the shoulder is fixed with a plaster sleeve, the sleeve does not put pressure, movements in adjacent joints are preserved, no neurotrophic disorders are detected in the distal parts of the limb.

Manipulation “**” month 2013 - immobilization with a DEZO plaster cast.

“**” month 2013 - replacement of the DEZO plaster cast with a plaster sleeve for the shoulder...

Due to the presence of inflammation and fixation of ANF of the humerus in the anamnesis, a decision was made on conservative treatment tactics for the patient. At the time of examination, the patient was given a referral for ITU 088u-06, the examination period was “**” month 2014.

1. Medicines: Thrombo ACC150 1t.1r.d for 30 days. Analgesics for pain (Ketarol, Ketaprofen, Analgin, Baralgin)

2. Limitation of movements in the elbow and shoulder joints at least 10 weeks from the moment of injury, then x-ray control.

4. X-ray control 8-12 weeks after the injury, to decide whether to stop immobilization.

5. Exercise therapy for the shoulder and elbow joint, with the exception of passive development of joints for up to 16 weeks with subsequent X-ray control and addressing the issue of the possibility of increasing range of motion due to active development based on the results of X-ray control.

6. Passing the ITU.

A certificate of incapacity for work was issued from “**” month 2014 to “**” month 2014.”

From the protocol of X-ray of the humerus of the Regional Clinical Consultative and Diagnostic Center, ***, dated “**” month 2014, it follows: “X-rays of the upper and middle third of the right shoulder in a plaster cast reveal a flaccid consolidating fracture of the middle third of the right humerus with angular displacement. The callus is expressed unevenly. Due to the presence of a plaster cast, it is difficult to judge the formation of a pseudarthrosis. Osteoporosis is noted."

From the radiographs presented for this study, the following is determined. “**” month 2013 – oblique transverse fracture of the upper third of the humerus with displacement. "**" month 2014 – gypsum bandage, there is no fusion of the fragments, a bone callus is formed. “**” month 2014 – plaster cast, ununited fracture of the upper third of the right humerus, the angle of the fracture is open outward, a callus is forming, osteoporosis is noted.

(2) Thus, according to the data presented for this study medical information, during treatment Full Name in N***koy clinical hospital the following shortcomings were committed, expressed in insufficient diagnosis and treatment.

In particular, consultations with specialists were carried out untimely, and the descriptions of radiographs by the radiologist were incomplete. There is no description of the radiographs of the skull and lower jaw upon admission of the patient. In the description of the radiograph of the lower jaw dated “**” month 2013, there is no description of the nature of the fracture or the position of the fragments. An examination by a neurologist was carried out on day 21. At the beginning of the medical history there is a note from a neurosurgeon without the date and time of examination. The record does not contain complaints, injury history, examination data or neurological status, only a brief diagnosis and no recommendations for additional examination and treatment. Consultations with a maxillofacial surgeon were carried out only on the 5th day. There is no description of the skull radiograph and the primary radiograph of the mandible.

The diagnosis also reflects injuries, some of which are not confirmed in the medical history, while another part of the injuries is not included in the diagnosis. The main diagnosis was formulated correctly, but the fracture of the 3rd and 4th ribs on the right was not sustained (x-ray from “**” month 2013), neuritis of the facial nerve. In addition, a fracture of the frontal bone, a fracture of the frontal sinus, hemosinusitis, and a nasal fracture are not confirmed by the available descriptions of radiographs and consultation with an otorhinolaryngologist. Closed tension pneumothorax is not confirmed. There is no radiological evidence for tension pneumothorax. When describing thoracentesis, signs of tension pneumothorax are not described.

As for the direct treatment of the patient, a number of shortcomings were made at the Yamal-Nenets Autonomous Okrug “N*** Central City Hospital”. Firstly, during PSO of facial wounds, a thorough inspection was not carried out and a fracture of the lower jaw was not detected. Secondly, the occurrence of complications after osteosynthesis of the lower jaw and the need for repeated surgery. It is not possible to establish the time of the fracture of the plate on the lower jaw, but on the date “**” month 2013, according to available data, the patient already had a complication of the operation - a fracture of the fixing plate on the lower jaw, which required a repeat operation. In this case, we can assume a defect in the plate itself (otherwise it will be difficult to explain its fracture on the 9th day in an inactive patient). Thirdly, drugs that stimulate fracture healing (FTL) were not used. Exercise therapy, massage. Fourthly, incomplete reposition of the mandibular fracture, instability of the metal structure and its repeated destruction (data from the P-image from the “**” month of 2013), as well as the occurrence of a complication of the mandibular fracture in the form of osteomyelitis. Fifthly, the patient experienced a complication after osteosynthesis of the humerus with a plate in the form of its breakage. In addition, according to National leadership according to traumatology, in fractures with an oblique or spiral long fracture line, comminuted and segmental fractures of the humerus diaphysis, when the surgeon is forced to use more than 6 screws to attach the plate, the threat of surgical trauma and complications increases. Therefore, in this case, it was advisable to use intramedullary osteosynthesis, as well as osteosynthesis with external fixation devices, which remain among the advanced methods of treating shoulder fractures.

In general, the short period of destruction of metal structures (both the lower jaw and the humerus) and their nature indicate insufficient strength of the material from which they are made, that is, their low quality. However, as follows from the radiographs presented for this study, even during repeated osteosynthesis, the reposition of fragments of both the lower jaw and the humerus was not carried out insufficiently, the edges of the fragments were not compared, and during the reposition of the AVF fracture of the right humerus there was an angular displacement (P-gram "**" month 2013). These violations led to a slowdown in the consolidation of the fracture, chronification of the process, deterioration of the patient’s condition and prolongation of treatment.

CONCLUSIONS.

Based on the analysis of the documentation submitted for this study and the research conducted, the specialist comes to the following conclusion:

Answer to question 1. When providing medical care to the name of the State Budgetary Institution of the Yamal-Nenets Autonomous Okrug “N***kaya Central City Hospital”, the following shortcomings were committed.

The diagnosis reflects injuries, some of which are not confirmed in the medical history, while another part of the injuries is not included in the diagnosis.
During PSO of facial wounds, a thorough inspection was not carried out, and a fracture of the lower jaw was not found during PSO.
In the treatment of fractures of the mandible and humerus, low-quality materials were used, which required repeated surgical interventions.
No drugs stimulating fracture healing or FTL were used. Exercise therapy, massage.
During repeated osteosynthesis, the reposition of fragments of both the lower jaw and the humerus was not carried out sufficiently, the edges of the fragments were not compared.

Answer to question 2. Deficiencies in the treatment of FIO, made by the specialists of the Yamal-Nenets Autonomous Okrug "N*** Central City Hospital", led to a slowdown in the consolidation of the fracture, chronification of the process and are in a direct cause-and-effect relationship with the deterioration of the patient's condition and the extension of the treatment period.

court medical expert, ___________

Candidate of Medical Sciences

Send your good work in the knowledge base is simple. Use the form below

Students, graduate students, young scientists who use the knowledge base in their studies and work will be very grateful to you.

Altai State Medical University

Department of Traumatology and Orthopedics

Head Department: Doctor of Medical Sciences, Professor Raspopova E.A.

Teacher: Candidate of Medical Sciences, Associate Professor A.V. Chantsev

CLINICAL HISTORY OF THE DISEASE

Sick:______

Clinical diagnosis:

Healed pertrochanteric fracture of the right femur in conditions of MOS SSA, complicated by inflammation of the spoke and rod tracts

Curators: students of 422 groups

Rozhkov I.A., Chapyeva M.V.

Supervision date 06/21/06

BARNAUL 2006

FULL NAME.________

Location________

Place of work: unemployed

Date of admission: 06/19/06

Date of supervision: 06/21/06

ANDCOMPLAINTS for impaired mobility in the hip and knee joints on the right.

ANAMNESISMORBI

He considers himself sick from 7:30 a.m. On March 4, 2006, when he suffered a domestic injury, he slipped in the yard of his house, fell, and felt sharp pain in my right leg, I could hardly get up. He called a paramedic, who administered an anesthetic, applied a splint from scrap materials, and sent him to the Central District Hospital in a passing car. There he was diagnosed with a pertrochanteric fracture of the right femur based on clinical signs and radiography. For 5 days he was in the Central District Hospital in skeletal traction. On March 10, 2006, he was taken to the trauma department of the Regional Clinical Hospital, where he was in skeletal traction for 2 weeks. On March 23, 2006, an operation was performed (metal osteosynthesis with the application of a pin-rod apparatus). On May 14, 2006 he was discharged from the hospital. On June 13, 2006, I got caught in the rain, the bandages got wet, on the same day I felt pain, burning, itching in the area where the metal structure was applied, the skin around the places where the needles exited turned red, and by the evening swelling appeared in the thigh area. From the Central District Hospital he was sent to the trauma department of the Regional Clinical Hospital. For 6 days I was at home due to lack of transport, I took ketones 3 times a day, one tablet. On June 19, 2006, he was admitted to the Regional Clinical Hospital with a diagnosis of a pertrochanteric fracture of the right femur in the conditions of MOS SSA, complicated by inflammation of the pin tracts. On the same day, an operation was performed to dismantle the SSA, dressings and anti-inflammatory therapy were prescribed.

ANAMNESISVITAE

Patient ______, born September 29, 1958. suffered: Botkin's disease, tuberculosis, venous diseases denies. Injuries suffered: fracture of the bones of the right forearm - 1967, fracture of the left clavicle - 1980, multiple fractures of the ribs - 1979, fracture of the toes of the right foot - 1996. Heredity is not burdened. There were no allergic reactions to previously taken medications. No blood transfusions were performed.

STATUSPRESENSCOMMUNIS

The general condition of the patient is satisfactory, consciousness is clear, position is active. The physique is proportional, the constitution is normosthenic. Posture is straight. Height 170 cm, weight 67 kg. Color skin flesh-colored, skin elasticity is not reduced, the skin is dry. The subcutaneous fat layer is poorly developed. The corners of the mouth are symmetrical, the color of the lips is pink. Oral mucosa Pink colour, wet. The tongue is pink, moist, the root is covered with a white coating. The tonsils do not protrude from behind the arches. The act of swallowing is not impaired.

Degree of development muscular system moderate. There is no bone curvature.

The shape of the chest is normosthenic, symmetrical. The chest is symmetrically involved in the act of breathing. Mixed breathing type. The respiratory rate is 18 per minute, breathing is vesicular, rhythmic, there is no wheezing. No pathological pulsation was detected in the cardiac or extracardiac region.

The pulse is synchronous in both arms, the pulse rate is 75 beats per minute, rhythmic, soft, full. Heart rate 75 per minute, normocardia, correct rhythm. Heart sounds are clear and rhythmic. On the arms: blood pressure s = 120\90 mm Hg; Blood pressure d =120\90mm Hg.

The abdomen is of the correct configuration, symmetrical, participates in the act of breathing, and is not swollen. No visible peristalsis or antiperistalsis was detected. The development of subcutaneous venous anastomoses was not detected. The abdomen is soft, muscle tone is preserved, and there is no muscle tension.

The act of defecation and urination is not impaired.

STATUSORTOPEDICUS

In an upright position it stands independently, straight. Moves with the help of crutches with partial support on the affected limb.

The head is located in the midline.

The shoulder girdles are located at the same level, length 19 cm on the right and left.

The chest is symmetrical, normosthenic in constitution, both halves of the chest equally take part in the act of breathing.

Waist triangles 6 cm on the right and left.

The wings of the ilium are at the same level.

Plumb the navel along the midline.

The physiological curves of the spine are moderately expressed.

The line of the spinous processes corresponds to the plumb line, the plumb line passes through the intergluteal fold.

The angles of the shoulder blades are at the same level.

Measurements	Right (cm)	Left (cm)
Relative length of the upper limb
Relative length of the lower limb
Absolute length: shoulder
Forearms


Shoulder circumference: Upper third
Middle third
Lower third
Forearm circumference: Upper third
Middle third
Lower third
Thigh circumference: Upper third
Middle third
Lower third
Calf circumference: Upper third
Middle third
Lower third

Range of motion measurements in large joints


Shoulder joint: flexion/extension
Abduction/adduction
External/internal rotation
Elbow joint: flexion/extension
Wrist joint: flexion/extension
Pronation/supination
Radial/ulnar deviation
Hip joint: flexion/extension
Abduction/adduction
External/internal rotation
Knee joint: flexion/extension
Ankle: dorsi/plantar flexion

STATUSLOKALIS

When examined in the area of the right thigh, the skin is of normal color. There is moderate swelling of the soft tissues of the thigh, spreading to the knee joint and partially to the distal parts of the right lower limb. In places where the rods pass, local hyperemia of the skin is noted. Movement in the hip and knee joints on the right is limited; movement in the right ankle joint is full. Sensitivity is not impaired.

ADDITIONAL RESEARCH METHODS

General blood analysis

Red blood cells - 3.8 * 10 12 / l

Platelets - 380 * 10 9 /l

Sugar - 5.1 mmol/l

Description of the radiograph dated June 19, 2006

On a targeted radiograph of the area hip joint and the proximal diaphysis of the femur in the direct projection, a healed pertrochanteric fracture of the femur is visible in the conditions of MOS SSA with displacement of fragments along the length. The neck-shaft angle is 133 0, which corresponds to the norm.

CLINICAL DIAGNOSIS AND ITS RATIONALE

Based on: the patient’s complaints about limited mobility in the hip and knee joints on the right; data from the medical history that the patient felt a sharp pain in the area of the right hip after a fall, was taken to the Central District Hospital, where he was diagnosed with a pertrochanteric fracture of the right femur, which was later confirmed in the Regional Clinical Hospital, where he underwent MOS SSA surgery; also data from the medical history about the wetting of the bandages and the subsequent appearance of pain, burning and itching in the area where the rods exit; objective examination data (impaired mobility in the hip and knee joints on the right, swelling of the soft tissues of the thigh with transfer to the knee joint and distal parts of the right lower limb, hyperemia of the skin in the places where the rods pass), data x-ray examination from 06/19/06 - healed pertrochanteric fracture of the right femur in the conditions of MOS, SSA, we make a diagnosis: healed pertrochanteric fracture of the right femur in the conditions of MOS, SSA, complicated by inflammation of the pin and rod tracts.

DIFFERENTIAL DIAGNOSIS

This fracture should be differentiated from a pathological fracture. The fact that the cause of this fracture was a trauma is supported by the fact that the patient felt a sharp pain after a fall, which, as a rule, does not happen with pathological fractures; as well as the absence in the anamnesis of indications that the patient has osteomyelitis. This lesion differs from a dislocation in the presence characteristic features fracture on radiographs (the fracture line and displacement of fragments are visible).

PLANTREATMENTS

1. anti-inflammatory therapy

Local application of Levomekol ointment

Taking oral antibiotics to prevent osteomyelitis

REHABILITATION PLAN

1. walking on crutches with moderate, increasing load for 1 month;

2. after 1 month, X-ray control, deciding on the issue of reaching full load;

3. gradual access to full load within 1-1.5 months;

4. during this entire time:

Exercise therapy aimed at developing joints,

Physiotherapy aimed at developing joints and relieving edema syndrome,

Massage aimed at developing joints and relieving swelling;

What influences the decision to remove a fixator?

Often, almost a third of operations to treat bone fractures are associated with complications. As a result, the retainers have to be removed earlier than planned. In addition, several trends have emerged in medicine that greatly complicate decisions on the removal of metal structures by traumatologists. Thus, every year more and more manufacturers of retainers appear and each uses new technologies, types of alloys and forms of retainers. Another factor is patient mobility. Often, having undergone surgery to treat a fracture in one clinic, the patient goes to another to remove the metal structures. Therefore, it is quite difficult for many doctors to decide whether to remove implants.

Current indications for retainer removal

All indications for surgery to remove retainers can be divided into two groups: absolute and relative. The absolute category includes the following indications:

Deep tissues became infected due to instability of fixation of the metal structure;
The patient's tendency to allergic reactions on certain type alloys or metal;
The appearance of a focus of suppuration at the site of the surgical wound even several months after surgery. Such cases are called “late suppuration”;
The structure has lost stability and began to loosen, while the fracture has not yet healed or a false joint has begun to form from the connective tissue;
If the removal of the fixative is one of the stages of treatment. This happens, for example, if osteosynthesis of the ankle was performed with the installation of a positioning screw. This screw must be removed after a certain period of time;
It is necessary to carry out orthopedic intervention according to indications, but the implant prevents this from happening;
If the patient refuses to remove the fixator, a complication or new disease may inevitably arise;
If a metal structure is installed in patients young who are in the period of growth - in this case, the retainer will simply inhibit bone growth, which can lead to deformation;
If patients have high physical activity With physical activity by occupation, for example, stuntmen, athletes, circus performers;
Compliance with military or professional medical board requirements;
A previously installed low-quality fixative, as well as cases where metal objects that were not intended for implantation, for example, a piece of a surgical drill or instrument, remained in the wound.

Relative indications include cases where the fixator causes psychological discomfort, as well as difficulties associated with wearing shoes or difficulties with simple activities. physical exercise. Also removal of metal structures after osteosynthesis shown to women childbearing age who are planning a pregnancy. This is explained by the fact that it has not yet been fully studied how this or that fixative alloy affects the fetus.

Contraindications to removing the fixator

In addition to the significant reasons why a doctor prescribes the removal of pins, wires and other bone-fixing elements, there are also serious contraindications to such operations. These include:

Cases when the fixator is located in such an anatomical area of the body that repeated surgery can lead to injury and damage to tissues and anatomically important nodes and organs. This applies to fixators located in the pelvis, in the anterior zone of the spine and in the shoulder region, if the radial nerve was isolated during the operation;
Hip fractures in elderly people suffering from osteoporosis. In such patients, the likelihood of recurrent femoral fracture after removal of the fixators reaches 70%.

Each patient is unique, so the decision to perform such an operation is made individually by the doctor. Our clinic has a special approach to each patient, so the doctor carefully weighs all the arguments for and against the operation. Thanks to modern equipment and extensive experience of doctors, the risks are minimal.

24.02.2009, 17:03

in January 2006, operation No. 67 was performed - open reposition, MOS plate of the left tibia.
Diagnosis = closed spiral comminuted fracture of both bones of the middle-lower third of the left leg with displacement of fragments.
photo of the fracture

I read about controversial issues regarding the removal of asymptomatic plates.
but I would like to hear your opinion, given that I want to ski again, as well as engage in other sports - paragliding, etc.
I am concerned about the issue of “fatigue” (did I spell it correctly?) fracture at the junction of metal.
For the first time after the injury, I was in the Carpathians, I started skiing, but I couldn’t ski, I was always afraid of such a fracture.
Besides, my leg still hurts.
I am 30 years old.
I am more inclined to think that it should not be touched, but a trip to the Carpathians shook my opinion.

Another question. After the operation, the stitches were not removed (I came to remove them, but the thread did not protrude, it was torn, as I understood, they were late, it should have been 1-2 days earlier). Now it looks like this (the thread is illuminated, it is black):
[Only registered and activated users can see links] ([Only registered and activated users can see links])
Isn’t it scary that the thread remains inside?

And the third question, maybe you can help, I experience bone pain in the morning (especially in the pelvic area). took calcium long time. took tests. Everything is okay. (I’ll give it if necessary). I did densitometry, in popular language they said that the age of the bone tissue was 39 years.
The pain sometimes goes away (it doesn’t last for weeks), then again. I found no connection with calcium intake.

24.02.2009, 19:09

It’s good that you read the discussion about removing (not removing) the plates. Whether to delete or not is a personal matter for everyone, but when doubts arise that create some problematic issues, my opinion is to delete and forget.
The thread can be removed along with the plate.
A counter question: why did you take calcium for a long time?

24.02.2009, 19:49

I am concerned about the issue of “fatigue” (did I spell it correctly?) fracture at the junction of metal.

A stress fracture should be expected when there is no union, the cyclic load when walking goes through the fixator. Here the bone has fused and the plate is not under load. That is, if there is a fracture, it will be due to repeated serious injury. In this case, the absence of a plate will not help.
There was really no point in taking “calcium”.

25.02.2009, 18:31

If a person leads sports life with a high probability of getting fractures (skiing, if in the Carpathians - then probably mountain skiing; paragliding in the foreseeable future), that is, there is a reason to remove the plate. I think it will be much easier for traumatologists, if anything)))))))

I did densitometry, and in popular language they said that the age of the bone tissue was 39 years.

But somehow I don’t really trust these “analyses” and “conclusions” of the specialists who produce them. Purely subjective opinion))) I have a feeling that this is all biased by companies selling this very “vital essential calcium"))) As a traumatologist, these conclusions are like a piece of cake for me. I see porosis - one design, there is no porosis - there are even more options. Moreover, porosis, whether it exists or not, is visible “even with the naked eye”)))
And all these statements: “at your 30, you look like 39” are crazy!

25.02.2009, 22:11

Dear doctors!
Please help me understand it completely, sorry for possibly stupid questions.:sorrys:
The topic, as you understand, is very important to me.:aa:
I understand that the risk from surgery to remove the plates is higher than the potential harm from the metal for the rest of your life.
I still wanted to understand this potential harm, help)

Doctor Adonin wrote

Those. Will my bone with the plate definitely be weaker than if I remove the plate and the holes heal? and how much weaker? will it be meaningful to ski boldly? I read that the holes do not always heal, what does this depend on?

Doctor Sereda Andrey wrote

I didn’t quite understand the abundance of terms: aa: am I at risk of developing a soft tissue defect?

Doctor Andrey wave wrote

Doctor Victor wrote there
“I saw several cases of osteomyelitis 15-20 years after MOS with the fixator not removed. This, of course, is not statistical data, but the destruction of the bone was significant and the consequences were also not very good. The patients really regretted that they did not remove the fixator on time.
I think that to a large extent the issue of removing an asymptomatic fixator also depends on the patient’s lifestyle (contact sports, parachuting, etc.) and on the complexity of removing the fixator."

25.02.2009, 22:59

Doctor Adonin wrote
“application of a plate is accompanied by detachment of the periosteum, which weakens the growth of the bone directly under the plate. Therefore, from a biomechanical point of view, there are arguments for removing the plate after healing of a fracture of the lower extremity (where the loads are much higher and more regular than on the arm)”

In your case, the periosteum was removed. The extent to which bone remodeling under the plate is weakened is unknown, as is the clinical significance of this weakening. Apparently, this weakening of remodeling can be neglected, since bone growth occurs “from the inside”, and blood flows from the outside. The fact that the fracture has healed indicates that there was enough blood for healing, and even more so for ongoing remodeling. Biomechanical arguments in this case are just a theory (reasonable), not confirmed.

Doctor Sereda Andrey wrote
"a soft tissue defect above the plate. There is probably still a difference between a plate located on the medial surface and on the lateral surface of the LBD. Let him be a young guy, what is the risk of soft tissue problems in 40 years? When varicose veins will he be treated the way it usually happens in our clinics? Well, or is he a heavy smoker with a hereditary predisposition to obliteration? Let's remember about type 2 diabetes, which is not there now, but will be in 30 years if the plate on the lateral malleolus is not removed."

In your case, the plate is placed under the muscles from the outside. The risk of bedsores is negligible.

Doctor Andrey wave wrote
“Changes in bone architecture due to load redistribution. The effect of load shunt and associated changes in bone architecture are well known to all of us. The most striking manifestation of this phenomenon is the so-called “fatigue” fractures at the ends of the metal structure.”

Those. once again: if everything has grown together, then there are no “fatigue” fractures?:ah:

Against the background of normal loads - no fractures. Against the background of the injury, which would have caused a fracture even without the plate, it will naturally occur with the plate. In this case, the nature of the fracture will differ from the typical one, and in the case new operation osteosynthesis will have an additional risk of complications, and the surgical technique itself will become more complicated. I think that in this case it is possible to use fracture risk prediction scales (FRAX, for example), but this issue has not been studied, just as the possible accuracy of these scales is not entirely clear, especially in relation to tibia fractures. We are aware of stress fractures at the edges of the plate, but they are rare. In principle, they occur more often when the biomechanical principles of osteosynthesis are violated, but again there is no evidence.

Doctor Andrey Verkhovsky ([Only registered and activated users can see links]) wrote
“Would the architecture of the bone tissue change over time, with the possible development of instability in the area of the metal structure and, as a result, an increase in the risk of re-fracture?”

Am I at risk of developing instability? how tall is he?

I don’t think this risk can be regarded as real.

As far as I understand, this is infectious diseases a few years after MOS. are there any other statistics? I don’t want osteomyelitis in 15 years)))))))
Late infectious complications have been described, and they can occur several years after surgery. Sometimes 5-7 years. In general, I am confused by such a late figure (15-20 years). There are probably third-party reasons here, and these cases should be dealt with especially carefully. There are no specific statistics on late infectious complications after plate osteosynthesis, or they are unknown to me. In general, the issue under consideration is a relatively “blank spot” in surgical orthopedics.

26.02.2009, 13:24

Sereda Andrey, thank you very much, exhaustively :)
How else can I convey this to my traumatologist: confused:

What about the thread?:aa:

And another question: is it normal for the leg to ache at the fracture site after 3 years? (when I squat and stand up, when I run, when I ski)

26.02.2009, 17:59

The fact that the thread remained inside is not scary. There is no point in specially chasing her. Only if the question of aesthetic scar correction arises.
Further, the fact that the leg hurts is a twofold sign. On the one hand, fractures that have already healed may ache for a long time. This fact is described in folk epics. On the other hand, this could just be a “symptomatic” plate. Those. the plate that can be removed.
By the way, the question of “overgrowing of screw holes” remained unanswered :)

26.02.2009, 22:10

On the other hand, this could just be a “symptomatic” plate. Those. the plate that can be removed.
WELL HERE:wall::crazy:

By the way, the question of “overgrowing of screw holes” remained unanswered.

26.02.2009, 22:46

WELL HERE:wall::crazy:
and how now to determine what it hurts?:confused:
The only option left is to delete it.

Yeah)))) and how to close it?:aa:
Time will close.

04.03.2010, 16:12

The only option left is to delete it.
Dear Sereda Andrey!:ax:
or other consultants in this section:ax:
you write ([Only registered and activated users can see links]) that diaphyses often break after removal of the plates.
please tell me, is the tibia (in my case, the lower third) a diaphysis?
and, if possible, the approximate percentage of subsequent fractures,
thank you :ah:

04.03.2010, 16:59

Yes, you have a diaphysis.
The risk of fracture after plate removal is a mathematical concept and of little interest to a specific patient.
In general, it can be noted that this risk is probably higher after removal of modern plates (with locking screws). The previous generation of plates probably had a lower risk of such problems.
In addition, the risk is higher if the screws are passed through both “walls” of the bone. This case is yours.
A specific calculation of the true frequency of repeated fractures after plate removal is difficult, since no targeted research has been carried out on this matter, and personal calculations are of little interest, since a patient with a repeated fracture may go to another hospital and we will not know anything about him.
If you want an abstract figure, then perhaps I’ll give a risk of 2-20%.
This wide range is due to the discipline of patients. Some people will jump with a parachute in a week after removal, while others will wait two or three months before active loads.
After removing metal from the tibial diaphysis, I prefer to recommend that patients reduce stress (exclude extreme sports, sports) for 2-4 months, depending on the type of plate removed and the type of screw insertion.

Ps - for some reason I associate the removal of asymptomatic plates with the phrase “This is an English thing!” from the film "Formula of Love". Remember how he used a raspatory (crowbar) to forge the carriage's undercarriage?

04.03.2010, 17:40

ps - for some reason I associate the removal of asymptomatic plates with the phrase “This is an English thing!” from the film "Formula of Love". Remember how he used a raspatory (crowbar) to forge the carriage's undercarriage?

Eh, this professional humor of yours)))))))))))))))):ay:
my traumatologist is also very cheerful:ag:

Somehow I don’t feel like skiing or paragliding right now, I’m completely intimidated))) while I’m on maternity leave. So, apparently, I have a small risk of re-fracture...

So what to do about overgrowing holes? will they be completely overgrown, or not?:wall:

[Only registered and activated users can see links] ([Only registered and activated users can see links])
turns outward.
Is this a marriage? :p

04.03.2010, 18:26

so what to do about the overgrowing of holes? will they be completely overgrown, or not?:wall:

Overgrown

What worries me most now is the risk from anesthesia for a multi-hour operation.

Well, right there. Use regional anesthesia. In the vast majority of cases, this operation lasts no more than an hour. Even with cosmetic stitches.

By the way, my leg (ankle and foot) when sitting in a yoga mudra pose
[Only registered and activated users can see links] ([Only registered and activated users can see links])
turns outward.
Is this a marriage? :p
It's difficult to say in absentia. If there are no other problems, then you can assume that you just have a leg with additional options, and not a defect.

04.03.2010, 22:15

pusssik, sorry for interfering. I also have a plate in my leg. But it bothers me. Not in the sense that the fracture site hurts (it doesn’t hurt me at all), but the place where the plate is is quite sensitive. Plate - with inside shins and can even be felt a little in the ankle area. In addition, if someone grabs my leg or even if I hit the area where it is located, it hurts. Therefore, I want to take it out as quickly as possible, i.e. a little over a year later (a little less than a year has passed since the fracture). Don't you have one?
Best regards, Maria

04.03.2010, 22:48

I can’t send you a private message, it’s not allowed...
In general, communication between patients in the topic is prohibited, but I don’t know how else to answer you.

May the moderators forgive me:rolleyes::ax:

More than 3 years have passed, and the fracture site is still sensitive, my ankle is less mobile,
the tissues seem to be a little swollen. if I hit this place, I feel discomfort; if the load on the leg is axial at an angle, then a sharp pain occurs.
Here.
I’m also inclined to take it out, but I just can’t get it together.

29.03.2010, 11:28

In the vast majority of cases, this operation lasts no more than an hour. Even with cosmetic stitches.

Good afternoon
It seems like I decided to remove the plate this week (3 years after the fracture).
Maybe you have some recommendations?))))
Pre-operative tests were prescribed - CBC, OAM, chest FG (why, I don’t understand), ECG.
regional anesthesia - did you mean epidural?

When walking, I feel unpleasant pressure in the area of the fracture, with such a load [Only registered and activated users can see links]
sometimes (when I put a lot of stress on my leg with MOS) a sharp pain occurs.
Do you think these sensations will go away after removing the plate?
and is the plate causing this pain?

Thank you in advance!

29.03.2010, 21:24

I found recommendations for preparing for surgery. Among the general (but definitely scientifically unfounded) recommendations, you can voice a trip to the dentist who will sanitize your oral cavity. This will likely reduce the risk of infectious complications during arthroplasty. Before surgery, it is better not to shave hair from the thigh (if any), but to pluck it with tongs or remove it with depilatory cream.

I just have a problem with my teeth - pulpitis (nerve inflammation, nerve necrosis) in remission. I planned treatment after a traumatologist. Perhaps it should be the other way around...
it is necessary? I already set the date for the surgery(((

When removing implants, such a measure is unnecessary. Those. You can put your teeth aside.

Key words: diaphyseal fractures, lower limbs, stable functional osteosynthesis, complications of osteosynthesis, impaired osteogenesis

Introduction. Choosing a treatment method for diaphyseal fractures long bones lower limbs is one of the pressing problems of modern traumatology. The relevance is due to both the frequency of these injuries, reaching up to 40% of injuries to the musculoskeletal system, and the large percentage of complications and unsatisfactory treatment outcomes for the above injuries.

The most common method of treating diaphyseal fractures of the long bones of the lower extremities is stable functional osteosynthesis according to AO (intraosseous and extraosseous).

The fundamental principles of stable functional osteosynthesis are: anatomical reposition, stable fixation of bone fragments, early active movements in the joints of the operated limb, which expands the possibilities of early functional treatment and rehabilitation. However, a number of authors believe that stable functional osteosynthesis using AO has its drawbacks, which sometimes lead to complications such as non-union of fractures, delayed consolidation, aseptic necrosis, myelitis, etc. . With stable functional osteosynthesis, anatomical reposition and tight fixation are achieved due to excessive trauma to bone tissue: drilling out the medullary canal using massive nails (with intramedullary osteosynthesis) or large soft tissue incisions exposing the fracture site and skeletonization of the bone (with external osteosynthesis). This leads to a deterioration of the already impaired blood flow in the fracture area, disruption of the normal process of osteogenesis, resulting in a number of complications.

In the last decade, a new direction in improving osteosynthesis has emerged, designated as biological or minimally invasive osteosynthesis, the purpose of which is to avoid the above complications.

The purpose of this work is to study the results, identify errors and complications in the treatment of fractures of the long bones of the lower extremities using the method of stable functional osteosynthesis, carried out at the Center for Orthopedic Orthopedics over the past 17 years.

Material and methods. In 1989-2006. in the Center for Orthopedic Orthopedics (Armenia, Yerevan), stable functional osteosynthesis was performed on 1484 patients with fractures of the diaphyses of the long bones of the lower extremities - 1305 (88%) with closed and 179 (12%) with open fractures.

Domestic injuries were registered in 39%, industrial - 30, sports - 0.5, falls from a height - 3, injuries from road traffic accidents - 27.5%.

51% of the victims were hospitalized in satisfactory condition, 42% in serious condition, 7% in very serious condition.

The age of the patients ranged from 17 to 76 years, of which 626 (42.2%) were aged 17-37 years, 688 (46.4%) - 37 - 57 years, 170 (11.4%) - 57-76 years .

Multiple fractures occurred in 208 (14%) patients, with fractures of two segments recorded in 158 patients, three segments in 50 patients, and 1276 (86%) patients had a fracture of one segment.

Patients were hospitalized in the Center for Emergency Hospital on the first day of injury - 1451 (97.8%), and 33 (2.2%) - from the second to seventh day after injury. 955(64.4%) patients had femoral fractures, 529(35.6%) had tibial fractures, 834(56.2%) had comminuted fractures, 352(23.7%) had oblique and oblique spiral fractures, 298 (20.1%) - transverse fractures. In 669 (45.1%) patients, the fracture was located in the middle third of the diaphysis, 460 (31%) - in the lower third, 355 (23.9%) - in the upper third.

Intramedullary nail osteosynthesis was performed in 608 (41%) patients, of which 438 (72.1%) cases were intraosseous osteosynthesis of the femur, 170 (27.9%) - tibia.

Intramedullary osteosynthesis was performed in 326 (53.6%) patients using the closed anterograde method, and in 282 (46.4%) patients using the open retrograde method. In all cases of intramedullary osteosynthesis of the tibia, osteosynthesis was performed using a closed (anterograde) method.

In 876 (59%) patients, external osteosynthesis with a plate was performed. Of these, 517(45.3%) had femoral fractures and 359(44.7%) had tibial fractures.

The distribution of patients according to the method of osteosynthesis performed and according to the damaged segment is given in Table. 1.

Table 1. Distribution of patients according to the method of osteosynthesis performed and according to the damaged segment

Osteosynthesis operations were performed in the first 7 days after injury in 688 (46.4%) patients, within 30 days - in 635 (42.8%), in the remaining 161 (10.8%) - more late dates. In our opinion, the most optimal timing the operation is carried out on the 5-7th day from the moment of injury, when the swelling begins to decrease and the trophism of the injured limb is restored.

In the preoperative period, in mandatory, skeletal traction was applied to the injured limb for the purpose of immobilization. We also consider it mandatory to prescribe exercise therapy and breathing exercises from the first day.

Most patients were operated on under spinal anesthesia. In the preoperative period, all patients received a course of prophylactic antibiotic therapy.

The choice of fixator (rod, plate) was determined depending on the nature and level of the fracture. I should note that, in our opinion, for diaphyseal fractures of the bones of the lower extremities, intraosseous osteosynthesis is more appropriate.

The immediate results of treatment were studied in all cases.

Of the 1484 patients who underwent stable functional osteosynthesis, in 93% the surgical wound healed by primary intention, and in 7% (104 patients) inflammation of the surgical wound occurred. Of all cases of inflammation, 30 (31.2%) inflammatory process was stopped without serious complications, in the rest - the wound festered. Of the 74 cases of wound suppuration, 41 (55.4%) were with hip fractures, 33 (44.6%) were with tibia fractures. During wound suppuration, 21 (28.4%) underwent intramedullary osteosynthesis with a nail: 14 (66.7%) of them - open retrograde, 7 (33.3%) - closed anterograde osteosynthesis, 53 (71.6%) patients bone osteosynthesis was performed with a plate. Of all the cases of wound suppuration, in 22 patients the wound closed during treatment, and in 52 cases a fistula formed, of which in 13 cases myelitis was detected by x-ray, in 39 - destruction in the fracture area and bone sequestration. These patients developed osteomyelitis, for which they were reoperated and received appropriate treatment.

Control examination of patients was carried out 2-4 and 10-12 months after surgery. All patients attended the first follow-up examination. Radiologically, by this time, 585 (96.2%) patients, out of 608 operated on with intramedullary osteosynthesis, showed signs of callus formation, and in 23 (3.8%) these signs were absent. During the first control examination, 804 (91.8%) patients, out of 876 patients operated on with external osteosynthesis, had radiographic signs of consolidation, while 72 (8.2%) had no signs of consolidation. 27 (1.8%) patients had persistent pain (18 of them were operated on with intramedullary osteosynthesis, 9 with bone osteosynthesis). In 11 (40.7%) of them, these pains subsequently decreased, and in 16 (59.3%) they remained, and 7 of them developed contracture of the ankle or knee joint due to this. During the first follow-up examination, 52 (3.5%) patients had active fistulas with purulent discharge. From total number Of the patients who came for the first follow-up, 21 (1.4%) were found to have fractures and deformations of the structure.

80% of the operated patients came for the second control examination, the rest came at a later date. In 594 (97.7%) patients operated on with intramedullary osteosynthesis, consolidation was observed radiographically, and in 14 (2.3%) callus was not detected. In 824 (94.1%) patients operated on with external osteosynthesis, during the second control examination, radiographic signs of consolidation were noted, and in 52 (5.9%) there was no callus. Of the 52 patients who had during the first follow-up examination purulent fistulas, in 39 (75%) osteomyelitic process was determined radiologically. We give two clinical examples.

1. Patient A.M., 39 years old. She had surgery in 1998. in the Russian Federation regarding a secondary open oblique fracture of both bones of the middle third of the leg, where a stable - functional extraosseous osteosynthesis with a plate was performed. A year later, I went to the Center for Emergency Hospital, where the diagnosis was made : ununited fracture of the middle third of the bones of the left leg, condition after MOS, postoperative osteomyelitis .

Rice. 1. An x-ray of the leg bones shows that the fracture is fixed with a plate and screws; foci of destruction and large bone sequesters are visible

2. Patient A.L., 33 years old. In 1995, she underwent surgery at the Central Orthopedic Hospital for a closed comminuted fracture of the upper third of the femur. Stable and functional intramedullary osteosynthesis with a nail and cerclage was performed. After 10 months, the patient was re-admitted to the Center for Emergency Hospital, where the diagnosis was made: non-united fracture of the upper third of the left femur, complicated by osteomyelitis, condition after MOS .

Rice. 2. An x-ray of the femur reveals a non-union fracture of the upper third of the femur, a gap between the bone fragment, large cortical sequesters, and foci of destruction are visible

Both patients were re-operated, the structure was removed, sequesternecrectomy, and extrafocal osteosynthesis were performed.

Of the total number of patients who came for the second control, 26 were found to have fractures and structural deformations. We give two clinical examples.

3. Patient B.A., 36 years old. She was operated on at the Center for OR in 2000. for a closed transverse fracture of the middle third of the femur. A stable and functional intramedullary nail osteosynthesis was performed. In 2002 contacted the Center for Orthopedic Hospital, where the diagnosis was made: refracture of the middle third of the left femur, condition after MOS, fracture of a metal nail.

Rice. 3. An X-ray of the hip reveals a refracture of the middle third of the femur, a fracture of a metal nail

4. Patient G.G., 50 years old. In 1999, she received a fracture in the middle third of her right shin. She was operated on at the Center for Orthopedic Orthopedics, where they performed stable and functional osteosynthesis of the tibia with a metal plate and screws. After 9 months, the patient contacted the Center for Emergency Hospital, where the diagnosis was made: refracture of both bones of the middle third of the right leg, condition after MOS, fracture of a metal plate.

Rice. 4. An x-ray of the lower leg shows refracture of both lower leg bones and a fracture of the metal plate

Both patients were re-operated, the structure was removed and reosteosynthesis was performed.

Results and discussion. The results of treatment were studied in 1484 patients with fractures of the diaphysis of the long bones of the lower extremities operated on with stable functional osteosynthesis. Treatment results were assessed based on restoration of the anatomical and functional integrity of the limb. Good results were recorded in 76.4% (1134), satisfactory - 13.1% (194), bad - 10.5% (156).

Of the total number of observed patients, complications were identified in 233 (15.7%), of which in 159 (68.2%) cases extramedullary osteosynthesis with a plate was performed, in 74 (31.8%) - intramedullary osteosynthesis with a nail (of which 53 (71.4%) - open, 21 (28.6%) - closed osteosynthesis).

Complications of osteosynthesis depending on its method are given in Table. 2.

table 2. Complications during stable functional osteosynthesis of diaphyseal fractures of long bones of the lower extremities

Type of metal structure	Complications during stable functional osteosynthesis
Type of metal structure	structural fracture	design deficiency	osteomyelitis	aseptic bone necrosis	slow consolidation	false joint	express. pain syndrome	Total
Plate

Total (% of total observations)								233 (15,7%)

The above complications were associated both with errors made during the operation and with the basic principles of stable functional osteosynthesis (rigid fixation, large surgical approaches, skeletonization of bone tissue, use of massive nails, etc.).

Literature

Abbasi B.R., Ayvazyan V.P., Manasyan M.M., Vardevanyan G.G. Surgical treatment diaphyseal fractures of the tibia. Abstract. report II Congress of Traumatologists and Orthopedists of the Republic of Armenia, Anniversary Conference dedicated to the 50th anniversary of the founding of the Center for Traumatology, Orthopedics and Rehabilitation of the Ministry of Health of the Republic of Armenia, Yerevan, 1996, p. 3-4.
Ayvazyan V.P., Tumyan G.A., Sokhakyan A.R., Abbasi B.R. A method for blocking fractures of long bones during osteosynthesis with standard pins. There, p. 6-8.
Baskevich M.Ya. Current aspects of closed intramedullary osteosynthesis, Russian Biomedical Journal, 2005, vol. 6, p. 30-36.
Betsisor V., Darchuk M., Kroitor G., Goyan V., Gergelejui A. Combined osteosynthesis in the treatment of diaphyseal fractures of long bones and their consequences, Mat. Congress of Traumatologists and Orthopedists of Russia with international participation, Yaroslavl, 1999, p. 65-67.
Gaiko G.V., Ankin L.N., Polyachenko Yu.V., Ankin N.L., Kostrub A.A., Laksha A.M. Traditional and minimally invasive osteosynthesis in traumatology, J. orthopedics, traumatology and prosthetics, 2000, 2, p. 73-76.
Grigoryan A.S., Tumyan G.A., Sanagyan A.A., Poghosyan K.J. Complications during intramedullary functionally stable osteosynthesis of long bones of the lower extremities, Sat. materials of the I International Medical Congress of Armenia, Yerevan, 2003, p. 98-99.
Mironov S.P., Gorodnichenko A.I. Treatment of long bone fractures with a new universal external fixation device. Mat. Congress of Traumatologists and Orthopedists of Russia with international participation, Yaroslavl, 1999, p. 265-266.

Stable and functional osteosynthesis of the diaphyses of long bones of the lower extremities - errors and complications. Removal of metal structures after osteosynthesis of the femur

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