Pakadali pano pokonza mkati mwa ma fracture a distal radius, pali njira zosiyanasiyana zotsekera ma anatomical plate zomwe zimagwiritsidwa ntchito kuchipatala. Ma fracture amkati awa amapereka yankho labwino pa mitundu ina yovuta ya ma fracture, ndipo m'njira zina amakulitsa zizindikiro za opaleshoni ya ma fracture osakhazikika a distal radius, makamaka omwe ali ndi osteoporosis. Pulofesa Jupiter wochokera ku Massachusetts General Hospital ndi ena afalitsa nkhani zingapo mu JBJS zomwe zapeza pa lock plate fixation ya ma fracture a distal radius ndi njira zina zochitira opaleshoni. Nkhaniyi ikuyang'ana kwambiri njira yopangira opaleshoni ya ma fracture a distal radius kutengera fracture block inayake.
Njira Zopangira Opaleshoni
Chiphunzitso cha mizati itatu, chozikidwa pa makhalidwe a biomechanical ndi anatomical a distal ulnar radius, ndicho maziko a chitukuko ndi kugwiritsa ntchito kwachipatala kwa dongosolo la mbale la 2.4mm. Kugawikana kwa mizati itatu kukuwonetsedwa pa Chithunzi 1.
Chithunzi 1 Chiphunzitso cha magawo atatu cha distal ulnar radius.
Mzere wozungulira ndi theka la mbali ya ...
Mzati wapakati ndi theka lapakati la distal radius ndipo umaphatikizapo lunate fossa (yogwirizana ndi lunate) ndi sigmoid notch (yogwirizana ndi distal ulna) pamwamba pa articular. Nthawi zambiri ikadzazidwa, katundu wochokera ku lunate fossa umatumizidwa ku radius kudzera mu lunate fossa. Mzati wa ulnar lateral, womwe umaphatikizapo distal ulna, triangular fibrocartilage, ndi inferior ulnar-radial joint, umanyamula katundu wochokera ku ulnar carpal bones komanso kuchokera ku inferior ulnar-radial joint ndipo umakhala ndi mphamvu yokhazikika.
Njirayi imachitika pogwiritsa ntchito mankhwala oletsa ululu a brachial plexus ndipo kujambula kwa X-ray mkati mwa opaleshoni ndikofunikira. Mankhwala opha tizilombo toyambitsa matenda m'mitsempha anaperekedwa mphindi 30 musanachite opaleshoni ndipo njira yopumira ya pneumatic tourniquet inagwiritsidwa ntchito kuchepetsa kutuluka kwa magazi.
Kukhazikika kwa mbale ya Palmar
Pa ma fractures ambiri, njira ya palmar ingagwiritsidwe ntchito kuwonetsa pakati pa radial carpal flexor ndi radial artery. Pambuyo pozindikira ndikubweza flexor carpi radialis longus, pamwamba pa minofu ya pronator teres imawonedwa ndipo kulekanitsidwa kooneka ngati "L" kumakwezedwa. Pa ma fractures ovuta kwambiri, brachioradialis tendon imatha kutulutsidwanso kuti ithandize kuchepetsa ma fracture.
Pini ya Kirschner imayikidwa mu radial carpal joint, zomwe zimathandiza kudziwa malire akutali kwambiri a radius. Ngati pali fracture yaing'ono pa articular margin, palmar 2.4mm steel plate ikhoza kuyikidwa pamwamba pa distal articular margin ya radius kuti ikhazikike. Mwa kuyankhula kwina, fracture yaing'ono pamwamba pa articular ya lunate ikhoza kuthandizidwa ndi 2.4mm "L" kapena "T" plate, monga momwe zasonyezedwera pa Chithunzi 2.
Pa ma fractures a extra-articular omwe achotsedwa fupa, ndikofunikira kuzindikira mfundo zotsatirazi. Choyamba, ndikofunikira kukonzanso fracture kwakanthawi kuti muwonetsetse kuti palibe minofu yofewa yomwe ili kumapeto kwa fracture. Kachiwiri, kwa odwala omwe alibe osteoporosis, fracture imatha kuchepetsedwa mothandizidwa ndi mbale: choyamba, screw yotsekera imayikidwa kumapeto kwa plate ya palmar anatomical, yomwe imalumikizidwa ku gawo la distal fracture lomwe lachotsedwa, kenako magawo a distal ndi proximal fracture amachepetsedwa mothandizidwa ndi mbaleyo, ndipo pomaliza, ma screws ena amayikidwa pafupi.
CHITHUNZI 3 Kusweka kwa extra-articular kwa distal radius yomwe yachotsedwa dorsally kumachepetsedwa ndikukhazikika kudzera mu njira ya palmar. CHITHUNZI 3-A Pambuyo pomaliza kuwonekera kudzera mu radial carpal flexor ndi radial artery, pini yosalala ya Kirschner imayikidwa mu radial carpal joint. Chithunzi 3-B Kuwongolera kwa metacarpal cortex yomwe yachotsedwa kuti ikonzedwenso.
Chithunzi 3-C ndi Chithunzi 3-DA chosalala cha Kirschner chimayikidwa kuchokera ku tsinde la radial kudzera mu mzere wosweka kuti akonze kwakanthawi kumapeto kwa fracture.
Chithunzi 3-E Kuwona bwino kwa munda wa opaleshoni kumachitika pogwiritsa ntchito retractor musanayike mbale. CHITHUNZI 3-F Mzere wakutali wa zomangira zokhoma umayikidwa pafupi ndi fupa la subchondral kumapeto kwa distal fold.
Chithunzi 3-G X-ray fluoroscopy iyenera kugwiritsidwa ntchito kutsimikizira malo a mbale ndi zomangira zakutali. Chithunzi 3-H Gawo loyandikira la mbale liyenera kukhala ndi malo otseguka (ngodya ya madigiri 10) kuchokera ku diaphysis kuti mbaleyo ikhale yolumikizidwa ku diaphysis kuti ikhazikitsenso chipika chakutali cha fracture. Chithunzi 3-I Limbitsani screw yapafupi kuti mubwezeretsenso kupendekera kwa palmar kwa distal fracture. Chotsani pini ya Kirschner musanamangitse screw kwathunthu.
Zithunzi 3-J ndi 3-K Zithunzi za X-ray zomwe zachitika pa opaleshoni zikutsimikizira kuti choswekacho chinasinthidwa kukhala malo ake ndipo zomangira za mbale zinayikidwa bwino.
Kukhazikitsa Mzere wa M'mimba Njira yochitira opaleshoni yowunikira mbali ya m'mimba ya distal radius imadalira kwambiri mtundu wa kusweka, ndipo ngati kusweka ndi zidutswa ziwiri kapena zingapo za intra-articular fracture, cholinga cha chithandizochi makamaka ndikukonza ma radial ndi medial columns nthawi imodzi. Pa opaleshoni, ma extensor support bands ayenera kudulidwa m'njira ziwiri zazikulu: motalikirana m'zigawo zachiwiri ndi zachitatu za extensor, ndi subperiosteal dissection ku 4th extensor compartment ndikubweza tendon yofanana; kapena support band incision yachiwiri pakati pa 4th ndi 5th extensor compartments kuti awonetse ma columns awiri padera (Chithunzi 4).
Choswekacho chimakonzedwa ndikukonzedwa kwakanthawi ndi pini ya Kirschner yosadulidwa, ndipo zithunzi za x-ray zimatengedwa kuti zitsimikizire kuti choswekacho chasweka bwino. Kenako, mbali ya dorsal ulnar (pakati pa mzere) ya radius imakhazikika ndi mbale ya 2.4 mm "L" kapena "T". Mbale ya dorsal ulnar imapangidwa kuti itsimikizire kuti ikugwirizana bwino mbali ya dorsal ulnar ya distal radius. Ma plates amathanso kuyikidwa pafupi ndi mbali ya dorsal ya distal lunate momwe zingathere, chifukwa mizere yofanana pansi pa mbale iliyonse imalola ma plates kupindika ndi kupangidwa popanda kuwononga ulusi m'mabowo a screw (Chithunzi 5).
Kukhazikitsa mbale ya radial column kumakhala kosavuta, chifukwa pamwamba pa fupa pakati pa zigawo zoyambira ndi zachiwiri za extensor ndi lathyathyathya ndipo zitha kukhazikika pamalo awa ndi mbale yopangidwa bwino. Ngati pini ya Kirschner yayikidwa mbali yakutali kwambiri ya radial tuberosity, kumapeto kwa distal kwa mbale ya radial column kumakhala ndi groove yomwe imagwirizana ndi pini ya Kirschner, yomwe siisokoneza malo a mbaleyo ndikusunga fracture pamalo ake (Chithunzi 6).
Chithunzi 4 Kuwonekera kwa pamwamba pa dorsal ya distal radius. Mzere wothandizira umatsegulidwa kuchokera ku gawo lachitatu la extensor interosseous ndipo extensor hallucis longus tendon imabwerera m'mbuyo.
Chithunzi 5 Pofuna kuyika mbali ya dorsal ya pamwamba pa lunate, mbale ya dorsal "T" kapena "L" nthawi zambiri imakhala yopangidwa ndi mawonekedwe (Chithunzi 5-A ndi Chithunzi 5-B). Pamene mbale ya dorsal yomwe ili pamwamba pa lunate yakhazikika, mbale ya radial column imakhazikika (Zithunzi 5-C mpaka 5-F). Mapepala awiriwa amayikidwa pa ngodya ya madigiri 70 kuti apititse patsogolo kukhazikika kwa mkati.
Chithunzi 6 Mbale ya radial column yapangidwa bwino ndipo yayikidwa mu radial column, polemba notch kumapeto kwa mbale, zomwe zimathandiza mbale kupewa kukhazikika kwakanthawi kwa pini ya Kirschner popanda kusokoneza malo a mbale.
Mfundo zofunika
Zizindikiro za Kukhazikika kwa Mbale ya Metacarpal
Kusweka kwa mafupa a metacarpal intra-articular (kusweka kwa mafupa a Barton)
Kusweka kwa mafupa a extra-articular komwe kwasokonekera (kusweka kwa mafupa a Colles ndi Smith). Kukhazikika kokhazikika kumatha kuchitika pogwiritsa ntchito ma screw plates ngakhale pali osteoporosis.
Kusweka kwa pamwamba pa metacarpal lunate articular
Zizindikiro za kukhazikika kwa mbale ya dorsal
Ndi kuvulala kwa ligament ya intercarpal
Kusweka kwa pamwamba pa cholumikizira cha dorsal lunate
Kusweka kwa mafupa a carpal olumikizana ndi radial sheated dorsally
Zotsutsana ndi kukonza mbale ya kanjedza
Matenda oopsa a osteoporosis okhala ndi zofooka zazikulu pantchito
Kusweka kwa dzanja la msana
Kukhalapo kwa matenda osiyanasiyana okhudzana ndi thanzi
Zotsutsana ndi kukonza mbale ya dorsal
Matenda ambiri okhudzana ndi zachipatala
Mafupa osachoka m'malo awo
Zolakwa zosavuta kuzipanga pokonza mbale ya kanjedza
Malo a mbaleyo ndi ofunikira kwambiri chifukwa mbaleyo sikuti imangothandiza fracture meg, komanso malo oyenera amalepheretsanso distal locking screw kuti isalowe mu radial carpal joint. Ma X-ray osamala omwe amawonetsedwa mkati mwa opaleshoni, omwe amawonetsedwa mbali yomweyo ndi radial intensity ya distal radius, amalola kuwona bwino pamwamba pa articular ya radial mbali ya distal radius, yomwe ingathenso kuwoneka bwino kwambiri poyika ma ulnar screws poyamba panthawi ya opaleshoni.
Kulowa kwa screw mu dorsal cortex kumakhala ndi chiopsezo choyambitsa extensor tendon ndikupangitsa kuti tendon iphulike. Ma screw otsekeka amagwira ntchito mosiyana ndi ma screw wamba, ndipo sikofunikira kulowa mu dorsal cortex ndi ma screw.
Zolakwa zosavuta kuzipanga ndi kukhazikika kwa mbale ya dorsal
Nthawi zonse pamakhala chiopsezo chakuti screw ilowe mu radial carpal joint, ndipo mofanana ndi njira yomwe yafotokozedwa pamwambapa poyerekeza ndi palmar plate, shot yozungulira iyenera kutengedwa kuti mudziwe ngati malo a screw ndi otetezeka.
Ngati kukhazikika kwa radial column kuchitidwa koyamba, zomangira mu radial tuberosity zidzakhudza kuwunika kwa kukhazikika kwa articular surface resurfacing ya lunate.
Zomangira zakutali zomwe sizinakulungidwe kwathunthu mu dzenje la zomangira zitha kusokoneza tendon kapena kuyambitsa kuphulika kwa tendon.
Nthawi yotumizira: Disembala-28-2023
