Tam sim no rau kev txhim kho sab hauv ntawm cov kab hluav taws xob distal tawg, muaj ntau yam anatomical locking phaj tshuab siv hauv tsev kho mob.Cov kev txhim kho sab hauv no muab cov kev daws teeb meem zoo dua rau qee hom pob txha pob txha, thiab qee txoj hauv kev nthuav dav cov lus qhia rau kev phais rau cov pob qij txha tsis ruaj khov, tshwj xeeb tshaj yog cov neeg muaj pob txha.Xibfwb Jupiter los ntawm Massachusetts General Tsev Kho Mob thiab lwm tus tau tshaj tawm cov ntawv xov xwm hauv JBJS ntawm lawv qhov kev tshawb pom ntawm kev xauv lub phaj fixation ntawm lub vojvoog pob txha thiab lwm yam kev phais.Tsab ntawv xov xwm no tsom mus rau kev phais txoj hauv kev rau kev txhim kho ntawm qhov tawg ntawm qhov tawg ntawm qhov tawg raws li kev kho sab hauv ntawm ib qho kev puas tsuaj tshwj xeeb.
Cov txheej txheem phais
Txoj kev xav peb-kem, raws li biomechanical thiab anatomical yam ntxwv ntawm lub distal ulnar radius, yog lub hauv paus rau kev txhim kho thiab kev kho mob daim ntawv thov ntawm 2.4 hli phaj system.Kev faib ntawm peb kab yog qhia hauv daim duab 1.
Fig. 1 Peb-kab txoj kev xav ntawm lub distal ulnar radius.
Cov kab ke sab nraud yog ib nrab ntawm lub distal radius, suav nrog cov navicular fossa thiab radial tuberosity, uas txhawb nqa cov pob txha carpal ntawm sab radial thiab yog lub hauv paus chiv keeb ntawm qee cov ligaments uas stabilize lub dab teg.
Cov kab nruab nrab yog nruab nrab ntawm ib nrab ntawm lub qhov hluav taws xob distal thiab suav nrog lub lunate fossa (txuas nrog lub lunate) thiab sigmoid notch (txuas nrog lub distal ulna) ntawm cov pob qij txha.Nquag loaded, lub load los ntawm lunate fossa yog kis mus rau lub vojvoog ntawm lub lunate fossa.Lub ulnar lateral kem, uas muaj xws li lub distal ulna, daim duab peb sab fibrocartilage, thiab inferior ulnar-radial sib koom, nqa loads ntawm lub ulnar carpal pob txha raws li zoo raws li los ntawm inferior ulnar-radial sib koom tes thiab muaj ib tug stabilizing nyhuv.
Cov txheej txheem yog ua nyob rau hauv brachial plexus anesthesia thiab intraoperative C-arm X-ray duab yog qhov tseem ceeb.Cov tshuaj tua kab mob hauv cov hlab ntsha tau muab tshuaj tsawg kawg 30 feeb ua ntej pib txheej txheem thiab siv pneumatic tourniquet los txo cov ntshav.
Palmar phaj fixation
Rau feem ntau cov pob txha, ib txoj hauv kev palmar tuaj yeem siv los pom ntawm cov radial carpal flexor thiab cov hlab ntsha radial.Tom qab txheeb xyuas thiab tshem tawm cov flexor carpi radialis longus, qhov sib sib zog nqus ntawm cov leeg pronator teres yog pom thiab qhov "L" zoo li kev sib cais yog nqa tawm.Hauv kev puas tsuaj ntau dua, cov leeg brachioradialis tuaj yeem raug tso tawm ntxiv kom pab txo qis pob txha.
Ib tug Kirschner tus pin yog muab tso rau hauv lub radial carpal sib koom, uas yuav pab tau los txhais cov distal-feem ntau txwv ntawm lub vojvoog.Yog hais tias muaj pob txha me me ntawm cov pob txha pob txha muaj nyob, lub palmar 2.4mm steel phaj tuaj yeem muab tso rau ntawm qhov chaw ntawm qhov chaw ntawm lub vojvoog rau kev kho.Nyob rau hauv lwm yam lus, ib tug me me pob txha loj ntawm lub articular nto ntawm lub lunate yuav tau txais kev txhawb los ntawm ib tug 2.4 hli "L" los yog "T" phaj, raws li qhia nyob rau hauv daim duab 2.
Rau dorsally displaced extra-articular fractures, nws yuav pab tau kom nco ntsoov cov ntsiab lus hauv qab no.Ua ntej, nws yog ib qho tseem ceeb kom rov kho qhov tawg ib ntus kom paub tseeb tias tsis muaj cov ntaub so ntswg nyob rau hauv qhov kawg ntawm pob txha.Thib ob, hauv cov neeg mob uas tsis muaj pob txha, pob txha tuaj yeem raug txo nrog kev pab ntawm lub phaj: thawj zaug, lub xauv ntsia hlau yog muab tso rau ntawm qhov kawg ntawm lub phaj palmar anatomical, uas yog ruaj khov rau qhov chaw distal tawg ntu, tom qab ntawd lub distal thiab Cov ntu ntu ntawm qhov sib thooj raug txo nrog kev pab ntawm lub phaj, thiab thaum kawg, lwm cov ntsia hlau tau muab tso rau ze ze.
FIGURE 3 Extra-articular fracture of the dorsally displaced distal radius is txo thiab tsau ntawm ib txoj hauv kev palmar.Daim duab 3-A Tom qab ua tiav ntawm qhov raug ntawm radial carpal flexor thiab cov hlab ntsha radial, tus pin Kirschner tus pin yog muab tso rau hauv radial carpal sib koom.Daim duab 3-B Manipulation ntawm cov hloov pauv metacarpal cortex rov pib dua.
Daim duab 3-C thiab daim duab 3-DA du Kirschner tus pin yog muab tso rau ntawm cov qia radial los ntawm txoj kab tawg kom kho qhov tawg ib ntus.
Fig. 3-E Kev pom zoo txaus ntawm qhov chaw ua haujlwm tau ua tiav los ntawm kev siv lub retractor ua ntej muab phaj tso.FIGURE 3-F Distal kab ntawm locking screws yog muab tso rau ze ntawm cov pob txha subchondral ntawm qhov kawg ntawm qhov distal quav.
Daim duab 3-G X-ray fluoroscopy yuav tsum tau siv los xyuas kom meej qhov chaw ntawm lub phaj thiab cov ntsia hlau distal.Daim duab 3-H Qhov ze ze ntawm lub phaj yuav tsum muaj qhov pom zoo kom muaj qee qhov kev tshem tawm (10 degree kaum sab xis) los ntawm diaphysis kom lub phaj tuaj yeem kho rau lub diaphysis kom rov pib dua qhov cuam tshuam ntawm qhov tawg.Daim duab 3-Kuv Tighten lub proximal ntsia hlau rau reestablish lub palmar inclination ntawm lub distal puas.Tshem tawm Kirschner tus pin ua ntej lub hau ntswj nruj nruj.
Cov duab 3-J thiab 3-K Intraoperative radiographic dluab paub meej tias qhov tawg yog thaum kawg anatomically repositioned thiab cov phaj screws tau txaus siab rau qhov chaw.
Dorsal Plate Fixation Txoj kev phais kom nthuav tawm lub dorsal nam ntawm lub qhov hluav taws xob distal nyob ntawm qhov feem ntau yog nyob ntawm hom pob txha, thiab nyob rau hauv cov ntaub ntawv ntawm ib tug pob txha muaj ob los yog ntau tshaj intra-articular fracture fragments, lub hom phiaj ntawm kev kho mob yog tsuas yog kho ob qho tib si. cov radial thiab cov kab nruab nrab ntawm tib lub sijhawm.Intraoperatively, lub extensor txhawb nqa bands yuav tsum tau incised nyob rau hauv ob txoj kev loj: longitudinally nyob rau hauv lub thib ob thiab 3rd extensor compartments, nrog subperiosteal dissection mus rau lub 4th extensor compartment thiab retraction ntawm cov leeg sib thooj;los yog ib tug thib ob pab band incision ntawm lub 4th thiab 5th extensor compartments kom nthuav tawm ob kab sib cais (Fig. 4).
Cov pob txha yog manipulated thiab kho ib ntus nrog ib tug unthreaded Kirschner tus pin, thiab radiographic dluab raug coj los txiav txim tias lub pob txha tawg yog zoo nyob.Tom ntej no, lub dorsal ulnar (nruab nrab kem) sab ntawm lub vojvoog yog stabilized nrog 2.4 hli "L" lossis "T" phaj.Lub dorsal ulnar phaj yog zoo li tus los xyuas kom meej haum rau lub dorsal ulnar sab ntawm lub distal radius.Cov phaj tseem tuaj yeem muab tso rau ze rau ntawm qhov dorsal ntawm qhov distal lunate li sai tau, raws li cov grooves nyob rau hauv qab ntawm txhua lub phaj tso cai rau cov phaj yuav khoov thiab zoo li tus yam tsis muaj kev puas tsuaj rau cov threads nyob rau hauv cov ntsia hlau qhov (Fig. 5) .
Kev kho ntawm radial kem phaj yog qhov yooj yim, raws li cov pob txha nto ntawm thawj thiab thib ob extensor compartments yog qhov tiaj tus thiab tuaj yeem kho tau hauv txoj haujlwm no nrog lub phaj zoo.Yog hais tias tus pin Kirschner tau muab tso rau hauv qhov kawg ntawm qhov chaw ntawm lub radial tuberosity, qhov kawg ntawm cov radial kem phaj muaj qhov zawj uas sib haum rau Kirschner tus pin, uas tsis cuam tshuam rau txoj hauj lwm ntawm lub phaj thiab tswj qhov tawg ntawm qhov chaw. (Daim duab 6).
Fig. 4 Kev nthuav tawm ntawm lub dorsal nto ntawm lub voj voog distal.Cov pab pawg txhawb nqa tau qhib los ntawm 3rd extensor interosseous compartment thiab extensor hallucis longus tendon yog thim rov qab.
Fig. 5 Rau fixation ntawm dorsal nam ntawm articular nto ntawm lub lunate, lub dorsal "T" los yog "L" phaj feem ntau yog zoo li tus (Fig. 5-A thiab Fig. 5-B).Thaum lub dorsal phaj nyob rau ntawm qhov chaw ntawm lub lunate tau ruaj ntseg, lub radial kem phaj tau ruaj ntseg (Daim duab 5-C txog 5-F).Ob daim hlau muab tso rau ntawm lub kaum sab xis ntawm 70 degrees rau ib leeg txhawm rau txhim kho kev ruaj ntseg ntawm kev txhim kho sab hauv.
Fig. 6 Lub radial kem phaj yog zoo li tus thiab muab tso rau hauv lub radial kem, ceeb toom rau ntawm qhov kawg ntawm lub phaj, uas tso cai rau lub phaj kom tsis txhob muaj ib ntus fixation ntawm lub Kirschner tus pin yam tsis cuam tshuam rau txoj hauj lwm ntawm lub phaj.
Cov ntsiab lus tseem ceeb
Indications rau Metacarpal Plate Fixation
Displaced metacarpal intra-articular fractures (Barton fractures)
tshem tawm cov pob txha pob txha ntxiv (Colles thiab Smith fractures).Kev txhim kho ruaj khov tuaj yeem ua tiav nrog cov ntsia hlau daim hlau txawm tias thaum muaj pob txha.
Displaced metacarpal lunate articular nto pob txha
Indications rau dorsal phaj fixation
Nrog intercarpal ligament raug mob
Displaced dorsal lunate pob qij txha pob txha
Dorsally sheared radial carpal pob txha pob txha dislocation
Contraindications rau palmar phaj fixation
Mob osteoporosis hnyav nrog rau kev ua haujlwm tseem ceeb
Dorsal radial dab teg tawg dislocation
Muaj ntau yam kev kho mob comorbidities
Contraindications rau dorsal phaj fixation
Ntau yam kev kho mob comorbidities
Cov pob txha tsis txav chaw
Ua yuam kev yooj yim ua nyob rau hauv palmar phaj fixation
Txoj hauj lwm ntawm lub phaj yog ib qho tseem ceeb heev vim hais tias tsis yog tsuas yog lub phaj txhawb cov pob txha pob txha, tab sis qhov chaw kom zoo kuj tiv thaiv lub distal locking ntsia hlau los ntawm intruding mus rau hauv lub radial carpal sib koom.Ua tib zoo intraoperative radiographs, projected nyob rau hauv tib txoj kev raws li lub radial inclination ntawm lub distal vojvoog, tso cai rau kom meej visualization ntawm articular nto ntawm lub radial sab ntawm lub distal vojvoog, uas kuj yuav ua tau kom pom tseeb dua los ntawm kev tso lub ulnar screws ua ntej lub sij hawm. kev ua haujlwm.
Screw nkag mus rau ntawm lub dorsal cortex yog qhov kev pheej hmoo ntawm provoking lub extensor tendon thiab ua rau cov leeg rupture.Locking screws ua qhov txawv ntawm cov ntsia hlau ib txwm, thiab nws tsis tas yuav nkag mus rau lub dorsal cortex nrog cov ntsia hlau.
Ua yuam kev yooj yim ua nrog dorsal phaj fixation
Muaj ib txwm muaj kev pheej hmoo ntawm cov ntsia hlau nkag mus rau hauv radial carpal sib koom ua ke, thiab zoo ib yam li txoj hauv kev uas tau piav qhia saum toj no hauv kev cuam tshuam rau lub phaj palmar, yuav tsum tau txhaj tshuaj oblique los txiav txim siab seb txoj haujlwm ntsia hlau puas ruaj ntseg.
Yog tias fixation ntawm radial kem ua ntej, cov ntsia hlau nyob rau hauv radial tuberosity yuav cuam tshuam rau kev ntsuam xyuas tom qab fixation ntawm articular nto resurfacing ntawm lub lunate.
Distal screws uas tsis tau screwed tag nrho rau hauv lub qhov ntsia hlau yuav ua rau cov leeg los yog ua rau cov leeg tawg.
Post lub sij hawm: Dec-28-2023
