Panopa, distal fractures utali wozungulira amachitiridwa m'njira zosiyanasiyana, monga pulasitala fixation, incision ndi kuchepetsa kukhazikika mkati, kunja fixation bulaketi, etc. Pakati pawo, palmar mbale fixation akhoza kukwaniritsa zotsatira zogwira mtima, koma mabuku ena amanena kuti Vuto mlingo wake ndi mkulu monga 16%. Komabe, ngati mbaleyo yasankhidwa bwino, kuchuluka kwa zovuta kumatha kuchepetsedwa. Kufotokozera mwachidule za mitundu, zisonyezo ndi njira zopangira opaleshoni ya palmar plating kwa distal radius fractures zimaperekedwa.
I. Mitundu ya distal radius fractures
Pali machitidwe angapo opangira ma fractures, kuphatikiza gulu la Müller AO lotengera anatomy ndi gulu la Femandez potengera kuvulala. Pakati pawo, gulu la Eponymic limaphatikizapo ubwino wamagulu am'mbuyomu, limaphatikizapo mitundu inayi ya fractures, ndipo imaphatikizapo Maleon 4-part fractures ndi Chaffer's fractures, yomwe ingakhale chitsogozo chabwino cha ntchito yachipatala.
1. Gulu la Müller AO - fractures ya intra-articular
Gulu la AO ndiloyenera kuphulika kwa distal radius ndipo amawagawa m'magulu atatu: mtundu wa A extra-articular, mtundu wa B partial intra-articular, ndi mtundu wa C ophatikizana onse. Mtundu uliwonse umagawidwanso m'magulu osiyanasiyana amagulu ang'onoang'ono potengera kuuma ndi zovuta za fracture.
Mtundu A: Kuphulika kwapadera
A1, kuphulika kwa chikazi cha ulnar, radius ngati kuvulala (A1.1, kuphulika kwa tsinde la ulnar; A1.2 kuphulika kosavuta kwa ulnar diaphysis; A1.3, kupasuka kwa ulnar diaphysis).
A2, Kuthyoka kwa utali wozungulira, wosavuta, wokhala ndi inset (A2.1, utali wozungulira popanda kupendekeka; A2.2, kupendekeka kwa dorsal kwa utali, mwachitsanzo, Pouteau-Colles fracture; A2.3, palmar tilt of radius, mwachitsanzo, Goyrand-Smith fracture).
A3, Kuthyoka kwa utali wozungulira, wopangidwa (A3.1, kufupikitsa kwa axial kwa radius; A3.2 kagawo kakang'ono koboola pakati pa radius; A3.3, kusweka kwa radius).
Mtundu B: kusweka pang'ono kwa articular
B1, kupasuka kwa radius, ndege ya sagittal (B1.1, mtundu wosavuta wotsatira; B1.2, mtundu wotsatizana; B1.3, mtundu wapakati).
B2, Kuthyoka kwa mkombero wa dorsal wa radius, mwachitsanzo, Barton fracture (B2.1, mtundu wosavuta; B2.2, kuphatikiza lateral sagittal fracture; B2.3, kuphatikiza dorsal dislocation of wrist).
B3, Kuthyoka kwa metacarpal rim ya radius, mwachitsanzo, anti-Barton fracture, kapena Goyrand-smith type II fracture (B3.1, lamulo losavuta lachikazi, chidutswa chaching'ono; B3.2, kuphulika kosavuta, chidutswa chachikulu; B3.3, fracture comminuted).
Mtundu C: kuphulika kwathunthu kwa articular
C1, kupasuka kwa radial ndi mtundu wosavuta wa mawonekedwe a articular ndi metaphyseal (C1.1, posterior medial articular fracture; C1.2, sagittal fracture of articular surface; C1.3, fracture of articular surface of articular surface).
C2, Radius fracture, simple articular facet, comminuted metaphysis (C2.1, sagittal fracture of articular facet; C2.2, coronal facet fracture of articular facet; C2.3, articular fracture yofikira ku tsinde lozungulira).
C3, fracture ya radial, comminuted (C3.1, kuphulika kosavuta kwa metaphysis; C3.2, kupasuka kwa metaphysis; C3.3, kuphulika kwapadera komwe kumapita ku tsinde la radial).
2.Kugawa kwa distal radius fractures.
Malinga ndi limagwirira kuvulala Femandez gulu akhoza kugawidwa 5 mitundu:.
Ma fractures a Type I ndi owonjezera-articular metaphyseal comminuted fractures monga Colles fractures (dorsal angulation) kapena Smith fractures (metacarpal angulation). Khungu la fupa limodzi limathyoka pansi pa kupsinjika ndipo cortex yotsutsana imasinthidwa ndikuphatikizidwa.
Kuthyoka
Mitundu yamtundu wa III ndi fractures ya intra-articular, yomwe imayambitsidwa ndi kumeta ubweya wa ubweya. Kuphulika kumeneku kumaphatikizapo kuphulika kwa kanjedza kwa Barton, kuphulika kwa dorsal Barton, ndi kuphulika kwa tsinde.
Kumeta nkhawa
Mitundu yachitatu ya fractures ndi intra-articular fractures ndi zolowetsa metaphyseal chifukwa cha kuvulala koponderezedwa, kuphatikizapo fractures zovuta za articular ndi radial pilon fractures.
Kulowetsa
Mtundu wa IV fracture ndi kuphulika kwa mitsempha ya ligamentous attachment yomwe imapezeka panthawi ya fracture-dislocation ya radial carpal joint.
Avulsion fracture I dislocation
Mtundu wa V fracture umachokera ku kuvulala kothamanga kwambiri komwe kumaphatikizapo mphamvu zambiri zakunja ndi kuvulala kwakukulu. (Zosakaniza I, II, IIII, IV)
3.Kulemba kwa zilembo
II. Chithandizo cha distal radius fractures ndi palmar plating
Zizindikiro.
Kwa fractures yowonjezera-articular yotsatira kulephera kwa kuchepetsa kutsekedwa muzochitika zotsatirazi.
Kuchuluka kwa dorsal kupitirira 20 °
Kuponderezana kwa dorsal kuposa 5 mm
Kufupikitsa kwakutali kopitilira 3 mm
Distal fracture block displacement yayikulu kuposa 2 mm
Kwa fractures ya intra-articular kuposa kusamuka kwa 2mm
Akatswiri ambiri samalimbikitsa kugwiritsa ntchito mbale za metacarpal chifukwa cha kuvulala kwamphamvu kwambiri, monga kusweka kwambiri kwa intra-articular comminuted fractures kapena kuwonongeka kwakukulu kwa mafupa, chifukwa zidutswa za distal fracture zimakhala zosavuta ku avascular necrosis ndipo zimakhala zovuta kuziyika.
Odwala omwe ali ndi tizidutswa tambiri tomwe timasweka komanso kusamuka kwakukulu ndi kufooka kwa mafupa, metacarpal plating sikugwira ntchito. Thandizo la subchondral la distal fractures likhoza kukhala lovuta, monga kulowa mkati mwazitsulo.
Njira ya opaleshoni
Madokotala ambiri ochita opaleshoni amagwiritsa ntchito njira yofananira ndi njira yofananira kukonza ma distal radius fractures ndi mbale ya palmar. Komabe, njira yabwino yopangira opaleshoni imafunika kuti mupewe zovuta zomwe zimachitika pambuyo pa opaleshoni, mwachitsanzo, kuchepetsa kungathe kutheka mwa kumasula chipika chophwanyika kuchokera kupsinjika kophatikizidwa ndikubwezeretsa kupitiriza kwa fupa la cortical. Kukonzekera kwakanthawi ndi zikhomo za 2-3 Kirschner zitha kugwiritsidwa ntchito, ndi zina.
(I) Preoperative repositioning ndi kaimidwe
1. Kukoka kumachitidwa molunjika ku shaft yozungulira pansi pa fluoroscopy, ndi chala chachikulu chikukankhira chotchinga chodutsa kuchokera kumbali ya palmar ndi zala zina zimakweza chipika chakutali m'mwamba kuchokera kumbali ya dorsal.
2. Malo ogona, ndi chiwalo chokhudzidwa pa tebulo lamanja pansi pa fluoroscopy.
(II) Malo olowera.
Pa mtundu wa njira yogwiritsidwira ntchito, PCR (radial carpal flexor) njira yowonjezera palmar ikulimbikitsidwa.
Mapeto akutali a kudulidwa kwa khungu kumayambira pakhungu la dzanja ndipo kutalika kwake kumatha kutsimikiziridwa molingana ndi mtundu wa fracture.
The radial flexor carpi radialis tendon ndi tendon sheath yake ndi incised, distal ku carpal mafupa ndi proximal pafupi ndi proximal mbali monga n'kotheka.
Kukoka kwa radial carpal flexor tendon ku mbali ya ulnar kumateteza mitsempha yapakati ndi flexor tendon complex.
Malo a Parona akuwonekera ndipo minofu ya anterior rotator ani ili pakati pa flexor digitorum longus (mbali ya ulnar) ndi mtsempha wamagazi (mbali ya radial).
Dulani mbali ya radial ya anterior rotator ani muscle, ndikuzindikira kuti gawo liyenera kusiyidwa kumtunda kuti limangidwenso.
Kukoka anterior rotator ani muscle ku mbali ya ulnar kumapangitsa kuti nyanga ya ulnar ikhale yokwanira pambali ya palmar ya radius.
Njira ya palmar imawulula mbali ya distal ndipo imawonetsa bwino mbali ya ulnar.
Kwa mitundu yovuta ya fracture, tikulimbikitsidwa kuti kuyimitsa kwa distal brachioradialis kumasulidwa, komwe kungathe kusokoneza kukoka kwake pa radial tuberosity, pomwe palmar sheath ya chipinda choyamba cha dorsal chitha kudulidwa, chomwe chingathe kuwonetsa distal fracture chipika radial ndi radial tuberosity, mkati tembenuzani utali wozungulira Yu kuti muphwanye malowo ndikuchotsanso malowo. block pogwiritsa ntchito pini ya Kirschner. Kwa fractures yovuta ya intra-articular, arthroscopy ingagwiritsidwe ntchito kuthandizira kuchepetsa, kuyesa ndi kukonza bwino kwa fracture block.
(III) Njira zochepetsera.
1. Gwiritsani ntchito fupa la fupa ngati lever kuti mukhazikitsenso
2. Wothandizira amakoka cholozera cha wodwalayo ndi zala zake zapakati, zomwe zimakhala zosavuta kukonzanso.
3. Pewani pini ya Kirschner kuchokera ku radial tuberosity kuti ikonzedwe kwakanthawi.
Pambuyo pokhazikitsanso, mbale ya palmar imayikidwa nthawi zonse, yomwe imayenera kukhala pafupi ndi madzi otsetsereka, iyenera kuphimba pamwamba pa ulnar, ndipo iyenera kukhala yoyandikana ndi pakati pa tsinde la radial. Ngati izi sizikukwaniritsidwa, ngati mbaleyo siili yolondola, kapena ngati kuyikanso sikuli kokwanira, ndondomekoyi siinali yangwiro.
Zovuta zambiri zimagwirizana kwambiri ndi malo a mbale. Ngati mbaleyo imayikidwa patali kwambiri ndi mbali ya radial, zovuta zokhudzana ndi bunion flexor zikhoza kuchitika; ngati mbaleyo imayikidwa pafupi kwambiri ndi mzere wamadzi, flexor yakuya ya chala ikhoza kukhala pangozi. Kuwonongeka kwapang'onopang'ono kwa fracture yokhazikika kumbali ya palmar kungapangitse kuti mbaleyo ipite kumbali ya palmar ndikulumikizana mwachindunji ndi flexor tendon, pamapeto pake imatsogolera ku tendonitis kapena ngakhale kupasuka.
Odwala osteoporotic, tikulimbikitsidwa kuti mbaleyo ikhale pafupi ndi mzere wamadzi momwe zingathere, koma osati kudutsa. Kukonzekera kwa subchondral kumatha kupezedwa pogwiritsa ntchito zikhomo za Kirschner zomwe zili pafupi kwambiri ndi ulna, ndipo zikhomo za Kirschner ndi zomangira zotsekera zimathandizira kupewa kuswekanso.
Mbaleyo ikayikidwa bwino, malekezero oyandikira amakhazikika ndi wononga imodzi ndipo mbali yotalikirapo ya mbaleyo imakhazikika kwakanthawi ndi mapini a Kirschner mu dzenje la ulnar kwambiri. Intraoperative fluoroscopic orthopantomograms, lateral view, ndi lateral mafilimu ndi 30 ° kukwezedwa dzanja anatengedwa kudziwa kuchepetsa fracture ndi malo kukhazikika mkati.
Ngati mbaleyo ili yokwanira bwino, koma pini ya Kirschner ndi intra-articular, izi zidzabweretsa kuchira kosakwanira kwa malingaliro a palmar, omwe angathe kuthetsedwa mwa kukonzanso mbale pogwiritsa ntchito "njira yokonza distal fracture" (Mkuyu 2, b).
Chithunzi 2.
a, zikhomo ziwiri za Kirschner zokhazikika kwakanthawi, zindikirani kuti kupendekera kwa metacarpal ndi malo owoneka bwino sanabwezeretsedwe mokwanira pakadali pano;
b, Pini imodzi ya Kirschner yokonza mbale kwakanthawi, zindikirani kuti utali wotalikirana wakhazikika panthawiyi (njira yokhazikika ya distal fracture block), ndipo gawo loyandikira la mbale limakokedwa kupita ku tsinde la radial kuti libwezeretse ngodya ya palmar.
C, kukonza bwino kwa malo a articular, kuyika kwa zomangira zotsekera / mapini, ndikukhazikitsanso komaliza ndi kukonza malo ozungulira.
Pankhani ya concomitant dorsal ndi ulnar fractures (ulnar / dorsal Die Punch), zomwe sizingakhazikitsidwe mokwanira pansi pa kutsekedwa, njira zitatu zotsatirazi zingagwiritsidwe ntchito.
Utali wozungulira umazungulira kutsogolo kutali ndi malo ophwanyika, ndipo chipika chophwanyika cha lunate fossa chimakankhidwira ku fupa la carpal kupyolera mu njira yotalikitsa PCR; choboola chaching'ono chimapangidwa ku dorsal kupita ku 4th ndi 5th compartments kuti awonetsetse chipika chophwanyika, ndipo chimakhazikika mu mbale ya ulnar forameni kwambiri. Kutsekedwa kwa percutaneous kapena pang'ono invasive fixation inkachitidwa ndi chithandizo cha arthroscopy.
Pambuyo pokhazikitsanso bwino ndikuyika mbaleyo moyenera, kukonza komaliza kumakhala kosavuta ndipo kuyikanso kwa anatomical kumatha kutheka ngati pini ya ulnar kernel yakhazikika bwino ndipo palibe zomangira zomwe zili mumphako (Chithunzi 2).
(iv) Kusankhira makonda.
Kutalika kwa zomangira kungakhale kovuta kuyeza molondola chifukwa cha kuphwanya kwakukulu kwa dorsal cortical bone. Zomangira zomwe zimakhala zazitali kwambiri zimatha kuyambitsa kugwedezeka kwa tendon komanso zazifupi kwambiri kuti zithandizire kukonza chipika cha dorsal fracture. Pachifukwa ichi olemba amalangiza ntchito ya ulusi zokhoma misomali ndi multiaxial loko misomali mu radial tuberosity ndi ambiri ulnar forameni, ndi ntchito kuwala-tsinde lokhoma zomangira mu malo otsala. Kugwiritsiridwa ntchito kwa mutu wosasunthika kumapewa kugwedezeka kwa tendon ngakhale itakulungidwa pamtunda. Pokonza mbale zolumikizirana, zomangira ziwiri zolumikizirana + zomangira imodzi wamba (zoyikidwa kudzera pa ellipse) zitha kugwiritsidwa ntchito kukonza.
Dr Kiyohito wochokera ku France adawonetsa zomwe adakumana nazo pogwiritsa ntchito mbale zotsekera za kanjedza zotchinga pang'onopang'ono pazidutswa za distal radius, pomwe maopaleshoni awo adachepetsedwa mpaka 1cm, zomwe ndi zotsutsana. Njirayi imasonyezedwa makamaka pazigawo zokhazikika za distal radius fractures, ndipo zizindikiro zake zopangira opaleshoni ndizowonongeka kwa zigawo za AO za mitundu A2 ndi A3 komanso kuphulika kwa intra-articular kwa mitundu C1 ndi C2, koma sikoyenera kwa C1 ndi C2 fractures kuphatikizapo fupa la intra-artipse. Njirayi siyoyeneranso kuphwanya mtundu wa B. Olembawo akuwonetsanso kuti ngati kuchepetsa ndi kukonza bwino sikungatheke ndi njirayi, m'pofunika kusinthira ku njira yachikhalidwe yocheka komanso kuti musamamatire pang'ono pang'ono.
Nthawi yotumiza: Jun-26-2024
