Tam sim no, cov pob qij txha ntawm cov pob qij txha tau kho nyob rau ntau txoj hauv kev, xws li plaster fixation, incision thiab txo sab hauv fixation, sab nrauv fixation bracket, thiab lwm yam. Ntawm lawv, palmar phaj fixation tuaj yeem ua tiav cov txiaj ntsig zoo dua, tab sis qee cov ntaub ntawv qhia tias nws qhov teeb meem yog siab li 16%. Txawm li cas los xij, yog tias lub phaj raug xaiv kom raug, qhov teeb meem yuav raug txo kom zoo. Cov lus piav qhia luv luv ntawm hom, cov cim qhia thiab cov txheej txheem phais mob ntawm palmar plating rau cov kab mob sib kis tau nthuav tawm.
I.Types ntawm distal radius fractures
Muaj ntau qhov kev faib tawm rau cov pob txha, suav nrog Müller AO kev faib tawm raws li lub cev thiab Femandez kev faib tawm raws li cov txheej txheem ntawm kev raug mob. Ntawm lawv, kev faib tawm Eponymic sib xyaw ua ke cov txiaj ntsig ntawm kev faib tawm yav dhau los, suav nrog plaub hom kev puas tsuaj, thiab suav nrog Maleon 4-ntu fractures thiab Chaffer's fractures, uas tuaj yeem yog cov lus qhia zoo rau kev kho mob.
1. Müller AO kev faib tawm - ib feem ntawm cov pob txha pob txha
Qhov kev faib tawm AO yog qhov zoo rau kev tawg paj tawg thiab faib ua peb yam tseem ceeb: hom A ntxiv-articular, hom B ib feem ntawm intra-articular, thiab hom C tag nrho cov pob txha pob txha. Txhua hom tau muab faib ua ntau yam sib txawv ntawm pawg sub raws li qhov hnyav thiab qhov nyuaj ntawm qhov tawg.
Hom A: Extra-articular puas
A1, ulnar femoral fracture, radius li raug mob (A1.1, ulnar qia pob txha; A1.2 yooj yim tawg ntawm lub ulnar diaphysis; A1.3, comminuted puas ntawm lub ulnar diaphysis).
A2, tawg ntawm lub vojvoog, yooj yim, nrog inset (A2.1, vojvoog tsis qaij; A2.2, dorsal qaij ntawm lub vojvoog, piv txwv li, Pouteau-Colles tawg; A2.3, palmar qaij ntawm lub vojvoog, piv txwv li, Goyrand-Smith tawg).
A3, Fracture ntawm lub vojvoog, comminuted (A3.1, axial shortening ntawm lub vojvoog; A3.2 wedge-shaped fragment of the radius; A3.3, comminuted fracture of the radius).
Hom B: ib nrab articular puas
B1, tawg ntawm lub vojvoog, sagittal dav hlau (B1.1, lateral simple type; B1.2, lateral comminuted type; B1.3, medial type).
B2, tawg ntawm dorsal rim ntawm lub vojvoog, piv txwv li, Barton puas (B2.1, hom yooj yim; B2.2, ua ke lateral sagittal fracture; B2.3, ua ke dorsal dislocation ntawm lub dab teg).
B3, Fracture ntawm metacarpal rim ntawm lub vojvoog, piv txwv li, ib qho kev tiv thaiv-Barton pob txha, lossis Goyrand-smith hom II pob txha tawg (B3.1, txoj cai yooj yim femoral, me me; B3.2, tawg yooj yim, tawg tawg loj; B3.3, comminuted puas).
Hom C: tag nrho articular puas
C1, radial tawg nrog tej yam yooj yim ntawm ob leeg articular thiab metaphyseal nto (C1.1, posterior medial articular puas; C1.2, sagittal puas ntawm articular nto; C1.3, tawg ntawm coronal nto ntawm articular nto).
C2, Radius tawg, yooj yim articular facet, comminuted metaphysis (C2.1, sagittal puas ntawm articular facet; C2.2, coronal facet puas ntawm articular facet; C2.3, articular fracture extending mus rau hauv radial qia).
C3, radial tawg, comminuted (C3.1, yooj yim tawg ntawm metaphysis; C3.2, comminuted fracture ntawm metaphysis; C3.3, articular fracture extending mus radial qia).
2.Classification ntawm distal radius tawg.
Raws li cov txheej txheem ntawm kev raug mob Femandez kev faib tawm tuaj yeem muab faib ua 5 hom:.
Hom I fractures yog cov pob txha metaphyseal comminuted fractures xws li Colles fractures (dorsal angulation) lossis Smith fractures (metacarpal angulation). Lub cortex ntawm ib pob txha tawg nyob rau hauv nro thiab lub contralateral cortex yog comminuted thiab embedded.
tawg
Hom III fractures yog intra-articular fractures, tshwm sim los ntawm shear stress. Cov pob txha no suav nrog palmar Barton fractures, dorsal Barton fractures, thiab radial qia pob txha.
Shear stress
Hom III fractures yog intra-articular fractures thiab metaphyseal insertions tshwm sim los ntawm compression raug mob, nrog rau cov pob txha pob txha thiab radial pilon fractures.
Insertion
Hom IV pob txha yog ib qho avulsion pob txha ntawm ligamentous txuas uas tshwm sim thaum tawg-dislocation ntawm radial carpal sib koom.
Avulsion fracture Kuv dislocation
Hom V pob txha yog tshwm sim los ntawm kev raug mob nrawm nrog ntau lub zog sab nraud thiab kev raug mob hnyav. (Ib, II, III, IV)
3.Eponymic ntaus ntawv
II.Kev kho mob ntawm cov pob qij txha ntawm cov pob qij txha nrog palmar plating
Cov lus qhia.
Rau cov pob txha ntxiv-articular tom qab tsis ua haujlwm ntawm kev kaw qhov txo qis hauv cov xwm txheej hauv qab no.
Dorsal angulation ntau dua 20 °
Dorsal compression ntau dua 5 mm
Distal radius shortening ntau dua 3 hli
Distal fracture block displacement ntau dua 2 hli
Rau cov pob txha intra-articular ntau dua 2 hli hloov chaw
Cov kws tshawb fawb feem ntau tsis pom zoo kom siv cov phaj metacarpal rau kev raug mob siab zog, xws li cov pob txha loj hauv cov pob txha comminuted los yog cov pob txha loj heev, vim tias cov pob txha pob txha no feem ntau ua rau avascular necrosis thiab nyuaj rau anatomically reposition.
Hauv cov neeg mob uas muaj ntau cov pob txha tawg thiab kev hloov pauv tseem ceeb nrog kev mob pob txha loj, metacarpal plating tsis zoo. Kev txhawb nqa subchondral ntawm cov pob txha tawg tuaj yeem muaj teeb meem, xws li cov ntsia hlau nkag mus rau hauv cov kab noj hniav sib koom ua ke.
Cov txheej txheem phais
Feem ntau cov kws phais neeg siv ib txoj hauv kev zoo sib xws thiab cov txheej txheem los kho cov kab mob sib kis nrog lub phaj palmar. Txawm li cas los xij, ib qho kev phais zoo yuav tsum tau ua kom zoo kom tsis txhob muaj teeb meem tom qab phais, xws li kev txo qis tuaj yeem ua tiav los ntawm kev tso cov pob txha pob txha los ntawm kev sib xyaw ua ke thiab rov ua kom cov pob txha cortical txuas ntxiv. Kev kho ib ntus nrog 2-3 Kirschner pins tuaj yeem siv, thiab lwm yam.
(I) Preoperative repositioning thiab posture
1. Traction yog ua nyob rau hauv cov kev taw qhia ntawm lub radial ncej nyob rau hauv fluoroscopy, nrog tus ntiv tes xoo nias lub proximal fracture block down los ntawm palmar sab thiab lwm tus ntiv tes nqa lub distal thaiv ntawm lub kaum sab xis ntawm lub dorsal sab.
2. Supine txoj hauj lwm, nrog rau cov ceg ceg ntawm tes ntawm tes hauv qab fluoroscopy.
(II) Cov ntsiab lus nkag.
Rau hom kev mus kom ze yuav tsum tau siv, PCR (radial carpal flexor) txuas ntxiv palmar mus kom ze yog pom zoo.
Lub distal kawg ntawm daim tawv nqaij incision pib nyob rau hauv daim tawv nqaij crease ntawm lub dab teg thiab nws ntev tuaj yeem txiav txim siab raws li hom pob txha.
Cov radial flexor carpi radialis tendon thiab nws cov leeg pob txha yog incised, distal rau cov pob txha carpal thiab proximal li ze rau sab proximal li sai tau.
Rub lub radial carpal flexor leeg mus rau sab ulnar tiv thaiv cov paj hlwb nruab nrab thiab flexor tendon complex.
Lub Parona qhov chaw raug nthuav tawm thiab lub anterior rotator ani leeg nyob nruab nrab ntawm lub flexor digitorum longus (ulnar sab) thiab cov hlab ntsha radial (radial sab).
Txiav lub radial sab ntawm lub anterior rotator ani cov leeg, sau tseg tias ib feem yuav tsum tau muab tso rau hauv lub vojvoog rau tom qab kev tsim kho.
Rub lub anterior rotator ani cov leeg mus rau sab ulnar tso cai rau kom txaus txaus ntawm lub ulnar horn ntawm lub palmar sab ntawm lub vojvoog.
Lub palmar mus kom ze nthuav tawm lub vojvoog distal thiab nthuav tawm lub kaum sab xis ulnar zoo.
Rau cov hom pob txha nyuaj, nws raug pom zoo tias qhov distal brachioradialis nres tuaj yeem tso tawm, uas tuaj yeem cuam tshuam nws rub ntawm radial tuberosity, ntawm qhov taw tes lub palmar sheath ntawm thawj dorsal compartment tuaj yeem incised, uas tuaj yeem nthuav tawm qhov cuam tshuam ntawm qhov tawg thaiv radial thiab radial tuberosity, sab hauv tig lub vojvoog ntawm qhov chaw, thiab rov ua dua. Intra-articular fracture block siv Kirschner tus pin. Rau cov pob txha pob txha hauv pob txha, arthroscopy tuaj yeem siv los pab txo qis, kev ntsuam xyuas thiab kev kho kom zoo ntawm cov pob txha pob txha.
(III) Kev txo qis.
1. Siv cov pob txha pry ua ib lub zog rau kev rov pib dua
2. Tus neeg pab rub tus neeg mob qhov ntsuas thiab nruab nrab ntiv tes, uas yuav yooj yim rau rov pib dua.
3. Screw lub Kirschner tus pin los ntawm radial tuberosity rau kev kho ib ntus.
Tom qab repositioning tiav lawm, ib tug palmar phaj yog niaj hnub muab tso, uas yuav tsum tau cia li nyob ze ntawm lub watershed, yuav tsum npog lub ulnar eminence, thiab yuav tsum nyob ze rau lub midpoint ntawm lub radial qia. Yog tias cov xwm txheej no tsis tau ntsib, yog tias lub phaj tsis yog qhov loj, lossis yog tias qhov kev hloov pauv tsis zoo, cov txheej txheem tseem tsis zoo tag nrho.
Muaj ntau yam teeb meem muaj feem xyuam nrog txoj hauj lwm ntawm lub phaj. Yog hais tias lub phaj muab tso rau deb dhau mus rau sab radial, cov teeb meem cuam tshuam nrog bunion flexor yuav tshwm sim; yog tias lub phaj muab tso rau ze ze rau ntawm txoj kab dej ntws, qhov sib sib zog nqus flexor ntawm tus ntiv tes yuav muaj kev pheej hmoo. Kev tshem tawm deformity ntawm cov pob txha repositioning mus rau sab palmar tuaj yeem yooj yim ua rau lub phaj protrude mus rau sab palmar thiab tuaj rau hauv kev sib cuag ncaj qha nrog cov leeg flexor, nws thiaj li ua rau tendonitis lossis rupture.
Hauv cov neeg mob osteoporotic, nws raug nquahu tias lub phaj yuav tsum tau muab tso rau ze li ntawm txoj kab dej ntws, tab sis tsis hla nws. Subchondral fixation tuaj yeem ua tiav siv Kirschner pins ze tshaj plaws rau lub ulna, thiab sab-los-sab Kirschner pins thiab locking screws yog qhov zoo hauv kev zam kom tsis txhob tawg rov qab.
Thaum lub phaj raug muab tso rau, qhov kawg ntawm qhov kawg yog kho nrog ib tus ntsia hlau thiab qhov kawg ntawm lub phaj yog kho ib ntus nrog Kirschner pins hauv qhov feem ntau ulnar. Intraoperative fluoroscopic orthopantomograms, lateral views, thiab lateral films nrog 30 ° lub dab teg elevation raug coj mus txiav txim qhov kev puas tsuaj ntawm pob txha thiab txoj hauj lwm ntawm lub internal fixation.
Yog tias lub phaj yog qhov txaus siab, tab sis Kirschner tus pin yog intra-articular, qhov no yuav ua rau rov qab tsis txaus ntawm lub palmar inclination, uas tuaj yeem daws tau los ntawm kev teeb tsa lub phaj siv "distal fracture fixation technique" (Fig. 2, b).
Daim duab 2.
a, ob lub Kirschner pins rau kev kho ib ntus, nco ntsoov tias cov metacarpal inclination thiab articular nto tsis txaus rov qab los ntawm lub sijhawm no;
b, Ib tug Kirschner tus pin rau ib ntus phaj fixation, nco ntsoov tias lub distal vojvoog yog tsau nyob rau hauv lub point no (distal fracture block fixation txheej txheem), thiab lub proximal feem ntawm lub phaj yog rub mus rau lub radial qia los kho lub palmar qaij lub kaum sab xis.
C, Arthroscopic fine-tuning ntawm articular nto, qhov chaw ntawm distal locking screws / pins, thiab zaum kawg resetting thiab fixation ntawm proximal vojvoog.
Nyob rau hauv cov ntaub ntawv ntawm concomitant dorsal thiab ulnar fractures (ulnar / dorsal Die Punch), uas tsis tuaj yeem rov pib dua zoo nyob rau hauv kaw, peb txoj kev siv hauv qab no yuav raug siv.
Lub vojvoog ze ze yog tig anteriorly deb ntawm qhov chaw tawg, thiab cov pob txha tawg ntawm lunate fossa raug thawb mus rau cov pob txha carpal los ntawm PCR lengthening mus kom ze; ib qho me me incision yog ua dorsal mus rau 4th thiab 5th compartments kom nthuav tawm cov pob txha pob txha, thiab nws yog ntsia hlau kho nyob rau hauv lub phaj feem ntau ulnar foramen. Kaw percutaneous lossis minimally invasive fixation tau ua nrog kev pab arthroscopic.
Tom qab txaus siab repositioning thiab muab tso rau ntawm lub phaj, qhov kawg fixation yog yooj yim dua thiab anatomical repositioning yuav ua tau tiav yog hais tias tus proximal ulnar kernel tus pin yog raug positioned thiab tsis muaj screws nyob rau hauv lub sib koom kab noj hniav (Daim duab 2).
(iv) Screw xaiv kev paub.
Qhov ntev ntawm cov ntsia hlau yuav nyuaj rau kev ntsuas kom raug vim qhov hnyav dorsal cortical pob txha crush. Screws uas ntev dhau lawm yuav ua rau muaj kev ntxhov siab ntawm cov leeg thiab luv dhau los txhawb kev kho ntawm dorsal fracture block. Vim li no, cov kws sau ntawv pom zoo kom siv cov ntsia hlau xauv cov ntsia hlau thiab cov ntsia hlau multiaxial xauv rau hauv radial tuberosity thiab feem ntau ulnar foramen, thiab siv lub teeb-stem locking screws nyob rau hauv seem seem. Kev siv lub taub hau blunt tsis txhob agitation ntawm cov leeg txawm tias nws yog threaded dorsally. Rau kev sib txuas ntawm cov phaj sib txuas, ob qhov sib txuas ntawm cov ntsia hlau + ib qho ntsia hlau (tso los ntawm lub voj voog) tuaj yeem siv rau kev kho.
Dr Kiyohito los ntawm Fab Kis tau nthuav tawm lawv cov kev paub dhau los ntawm kev siv cov pam tuag tsawg kawg nkaus rau cov pam tuag rau cov pob qij txha tawg, qhov chaw uas lawv qhov kev phais raug txo mus rau qhov siab tshaj 1cm, uas yog qhov tsis txaus ntseeg. Txoj kev no feem ntau yog qhia rau cov kab mob sib kis tau ruaj khov, thiab nws cov ntaub ntawv phais mob yog rau cov pob txha pob txha ntxiv ntawm AO fractions ntawm hom A2 thiab A3 thiab intra-articular fractures ntawm hom C1 thiab C2, tab sis nws tsis tsim nyog rau C1 thiab C2 pob txha tawg ua ke nrog cov pob txha loj. Txoj kev no kuj tsis haum rau hom B puas. Cov kws sau ntawv kuj tau taw qhia tias yog tias kev txo qis thiab kho tsis tuaj yeem ua tiav nrog txoj kev no, nws yuav tsum tau hloov mus rau txoj kev phais ib txwm siv thiab tsis txhob lo rau qhov kev txiav me me me me.
Post lub sij hawm: Jun-26-2024
