Pakadali pano, pali njira zosiyanasiyana zochizira kusweka kwa ma radius a distal, monga kukhazikika kwa pulasitala, kutsekeka kwa open ndi kukhazikika kwamkati, chimango chokhazikika chakunja, ndi zina zotero. Pakati pawo, kukhazikika kwa volar plate kumatha kukhala ndi zotsatira zabwino kwambiri, koma pali malipoti m'mabuku omwe amawonetsa kuti zovuta zake ndi zokwera kufika pa 16%. Komabe, ngati mbale yachitsulo isankhidwa bwino, kuchuluka kwa zovuta kumatha kuchepetsedwa bwino. Pepalali likufotokoza mwachidule makhalidwe, zizindikiro, zotsutsana, ndi njira zopangira opaleshoni ya volar plate treatment ya distal radius fractures.
1. Pali ubwino waukulu wa mbale ya mbali ya kanjedza
A. Imatha kuletsa mphamvu yogwirira ntchito. Kukhazikitsa ndi zomangira zokhoma kumathandizira chidutswa cha distal ndikusamutsa katunduyo ku radial shaft (Chithunzi 1). Imatha kupeza chithandizo cha subchondral bwino kwambiri. Dongosolo la plate silingathe kukonza bwino ma fracture a distal intra-articular, komanso limatha kubwezeretsa bwino kapangidwe ka anatomical ka fupa la subchondral intra-articular kudzera mu peg/screw "yokhala ngati fan". Kwa mitundu yambiri ya distal radius fractures, dongosololi limapereka kukhazikika kowonjezereka komwe kumalola kusuntha msanga.
Chithunzi 1, a, pambuyo pa kukonzanso kwa magawo atatu a kusweka kwa radius komwe kwakhala kozungulira, samalani kuchuluka kwa kupsinjika kwa dorsal; b, kuchepetsa kwenikweni kwa kusweka, cholakwikacho chiyenera kukonzedwa ndikuthandizidwa ndi mbale; c, mawonekedwe ambali pambuyo pa kukonzedwa kwa DVR, muvi umasonyeza kusamutsa katundu.
B. Kuchepa kwa mphamvu pa minofu yofewa: kukhazikika kwa volar plate kuli pansi pang'ono pa mzere wa madzi, poyerekeza ndi dorsal plate, kumatha kuchepetsa kuyabwa kwa tendon, ndipo pali malo ambiri omwe angapezeke, omwe angapewe bwino kukhudzana mwachindunji ndi implant ndi tendon. Kuphatikiza apo, ma implant ambiri amatha kuphimbidwa ndi pronator quadratus.
2. Zizindikiro ndi zotsutsana pakuchiza radius ya distal ndi volar plate
a. Zizindikiro: Pakulephera kuchepetsa kutsekedwa kwa mafupa osweka a extra-articular, zinthu zotsatirazi zimachitika, monga dorsal angulation yoposa 20°, dorsal compression yoposa 5mm, distal radius shortening yoposa 3mm, ndi distal fracture fracture displacement yoposa 2mm; Kusuntha kwa fracture yamkati ndi yoposa 2 mm; chifukwa cha kuchepa kwa mafupa, n'zosavuta kuyambitsa re-displacement, kotero ndi yoyenera kwambiri kwa okalamba.
b. Zoletsa: kugwiritsa ntchito mankhwala oletsa ululu am'deralo, matenda opatsirana am'deralo kapena am'thupi, khungu loipa kumbali ya volar ya dzanja; fupa ndi mtundu wa fracture pamalo osweka, mtundu wa fracture ya dorsal monga Barton fracture, radiocarpal joint fracture and dislocation, simple radius Styloid process fracture, small avulsion fracture of volar margin.
Kwa odwala omwe ali ndi kuvulala kwamphamvu kwambiri monga kusweka kwa mafupa komwe kumalumikizidwa mkati mwa articular kapena kutayika kwa mafupa kwambiri, akatswiri ambiri samalimbikitsa kugwiritsa ntchito ma volar plates, chifukwa kusweka kwa distal koteroko kumakhala ndi vuto la mitsempha yamagazi ndipo kumakhala kovuta kupeza kuchepa kwa thupi. Kwa odwala omwe ali ndi zidutswa zingapo zosweka komanso kusamuka kwakukulu komanso kufooka kwa mafupa kwambiri, volar plate ndi yovuta kugwira ntchito. Pakhoza kukhala mavuto ndi chithandizo cha subchondral pakusweka kwa distal, monga kulowa kwa screw mu cholumikizira. Mabuku aposachedwa adanenanso kuti pamene milandu 42 ya kusweka kwa intra-articular idachiritsidwa ndi ma volar plates, palibe ma articular screws omwe adalowa mu cholumikizira cha articular, chomwe chinali chogwirizana kwambiri ndi malo a ma plates.
3. Luso la opaleshoni
Madokotala ambiri amagwiritsa ntchito njira yolumikizira ma volar plate kuti athetse kusweka kwa distal radius m'njira ndi njira zofanana. Komabe, kuti tipewe mavuto omwe amabwera pambuyo pa opaleshoni, njira yabwino kwambiri yochitira opaleshoni imafunika, mwachitsanzo, kuchepetsako kungapezeke mwa kumasula kupsinjika kwa chotchinga cha fracture ndikubwezeretsa kupitiriza kwa fupa la cortical. Kulumikiza kwakanthawi ndi mawaya 2-3 a Kirschner kungagwiritsidwe ntchito. Ponena za njira yogwiritsira ntchito, wolembayo amalimbikitsa PCR (flexor carpi radialis) kuti iwonjezere njira yolumikizira ma volar.
a, Kukhazikika kwakanthawi ndi mawaya awiri a Kirschner, dziwani kuti kupendekera kwa volar ndi pamwamba pa articular sikunakonzedwenso mokwanira panthawiyi;
b, Waya wa Kirschner umakonza mbale kwakanthawi, samalani ndi kukhazikika kwa malekezero akutali a radius panthawiyi (njira yokhazikitsira zidutswa za distal fracture), gawo loyandikira la mbaleyo limakokedwa kupita ku radial shaft kuti libwezeretse kupendekera kwa volar.
C, Pamwamba pa articular pakonzedwa bwino pogwiritsa ntchito arthroscopy, screw/pin yotsekera ya distal imayikidwa, ndipo proximal radius imachepetsedwa ndikukhazikika.
Mfundo zazikuluNjira yofikira: Kudula khungu lakutali kumayambira pakhungu lopindika padzanja, ndipo kutalika kwake kumatha kudziwika malinga ndi mtundu wa kusweka. Mnofu wa flexor carpi radialis ndi chidendene chake zimadulidwa kutali ndi fupa la carpal komanso pafupi momwe zingathere. Kukoka mnofu wa flexor carpi radialis kumbali ya ulnar kumateteza mitsempha yapakati ndi flexor tendon complex. Malo a Parona amaonekera, ndipo pronator quadratus ili pakati pa flexor hallucis longus (ulnar) ndi radial artery (radial). Kudula kunapangidwa kumbali ya radial ya pronator quadratus, ndikusiya gawo lolumikizidwa ku radius kuti limangidwenso pambuyo pake. Kukoka pronator quadratus kumbali ya ulnar kumawonetsa bwino ngodya ya volar ulnar ya radius.
Pa mitundu yovuta ya kusweka, tikulimbikitsidwa kumasula kulowetsedwa kwa minofu ya brachioradialis, komwe kungathe kuletsa kukoka kwake pa njira ya radial styloid. Panthawiyi, chipolopolo cha volar cha chipinda choyamba cha dorsal chikhoza kudulidwa kuti chiwonetse kusweka kwa distal. Tsekani mbali ya radial ndi njira ya radial styloid, zungulirani mkati mwa radial shaft kuti mulekanitse ndi malo osweka, kenako gwiritsani ntchito mawaya a Kirschner kuti muchepetse block ya fracture ya intra-articular. Pa kusweka kovuta kwa intra-articular, arthroscopy ingagwiritsidwe ntchito kuthandiza kuchepetsa, kuwunika, komanso kukonza bwino zidutswa za fracture.
Pambuyo poti kuchepetsa kwatha, volar plate imayikidwa nthawi zonse. Mbale iyenera kukhala pafupi ndi malo otsetsereka madzi, iyenera kuphimba njira ya ulnar, ndipo mapeto a proximal a mbaleyo ayenera kufika pakati pa radial shaft. Ngati zinthu zomwe zili pamwambapa sizinakwaniritsidwe, kukula kwa mbale sikuli koyenera, kapena kuchepetsa sikuli kokwanira, ntchitoyo siili bwino.
Mavuto ambiri amakhudzana kwambiri ndi malo omwe mbaleyo imayikidwaNgati mbaleyo yayikidwa mozungulira kwambiri, mavuto okhudzana ndi flexor hallucis longus amakhalapo; ngati mbaleyo yayikidwa pafupi kwambiri ndi mzere wa madzi, flexor digitorum profundus ikhoza kukhala pachiwopsezo. Kuchepa kwa kusweka kwa volar displacement deform kungayambitse mosavuta kuti mbale yachitsulo ituluke mbali ya volar ndikukhudza mwachindunji flexor tendon, zomwe pamapeto pake zimapangitsa kuti tendinitis kapena kuphulika.
Kwa odwala matenda a mafupa, ndi bwino kuti mbaleyo ikhale pafupi ndi mzere wa madzi momwe mungathere, koma osati kudutsaMawaya a Kirschner angagwiritsidwe ntchito kukonza subchondral yomwe ili pafupi ndi ulna, ndipo mawaya a Kirschner omwe ali pafupi ndi mbali ndi misomali ndi zomangira zokhoma zimatha kuletsa bwino kusweka kwa fupa kuti lisalowenso m'malo mwake.
Pambuyo poti mbaleyo yayikidwa bwino, mapeto apafupi amakhazikika ndi sikurufu, ndipo dzenje la ulnar kumapeto kwa mbaleyo limakhazikika kwakanthawi ndi waya wa Kirschner. Mawonekedwe a fluoroscopy a anteroposterior, mawonekedwe a lateral, kukwera kwa dzanja ndi 30° lateral view, kuti adziwe kuchepetsa kusweka ndi malo okhazikika mkati. Ngati malo a mbaleyo ndi okhutiritsa, koma waya wa Kirschner uli mu cholumikizira, izi zipangitsa kuti volar intensity isabwererenso mokwanira, zomwe zingatheke pokonzanso mbaleyo kudzera mu "njira yokhazikitsira kusweka kwa distal" (Chithunzi 2, b).
Ngati ikuphwanyika mphuno ndi m'chiuno (ulnar/dorsal Die Punch) ndipo singachepe mokwanira pamene ikutsekedwa, njira zitatu zotsatirazi zingagwiritsidwe ntchito:
1. Ikani mbali yapafupi ya radius kuti isafike pamalo osweka, ndikukankhira lunate fossa fracture kupita ku carpus kudzera mu njira yowonjezera ya PCR;
2. Pangani kachidutswa kakang'ono kumbali ya dorsal ya chipinda chachinayi ndi chachisanu kuti muwonetsetse chidutswa choswekacho, ndikuchikonza ndi zomangira m'bowo la lateral kwambiri la mbale.
3. Kutsekeka kwa percutaneous kapena kocheperako pang'ono pogwiritsa ntchito arthroscopy.
Pambuyo poti kuchepetsako kwakwanira ndipo mbaleyo yayikidwa bwino, kukhazikika komaliza kumakhala kosavuta. Ngati waya wa proximal ulnar Kirschner wayikidwa bwino ndipo palibe zomangira zomwe zili m'malo olumikizirana, kuchepetsa kwa anatomical kungapezeke.
Chidziwitso chosankha zomangira: Chifukwa cha kusokonekera kwakukulu kwa fupa la dorsal cortical, kutalika kwa screw kungakhale kovuta kuyeza molondola. Zomangira zazitali kwambiri zingayambitse kuyabwa kwa tendon, ndipo zomangira zazifupi kwambiri sizingathe kuthandizira ndikukonza chidutswa cha dorsal. Pachifukwa ichi, wolembayo akulangiza kugwiritsa ntchito zomangira zokhoma zokhala ndi ulusi ndi zomangira zokhoma zambiri mu radial styloid process ndi most ulnar hole, ndikugwiritsa ntchito zomangira zokhoma zopukutidwa ndi ndodo m'malo ena onse. Kugwiritsa ntchito nsonga yosalala kumapewa kuyabwa kwa tendon ngakhale ngati dorsal exit ikugwiritsidwa ntchito. Pa proximal interlocking plate fixation, zomangira ziwiri zokhoma + screw imodzi yamba (yoyikidwa kudzera mu ellipse) zingagwiritsidwe ntchito pokhoma.
4. Chidule cha nkhani yonse:
Kukhazikitsa misomali ya msomali ya distal radius fractures kungathandize kwambiri pachipatala, zomwe zimadalira kwambiri kusankha zizindikiro ndi luso lapamwamba la opaleshoni. Kugwiritsa ntchito njira imeneyi kungathandize kuti pakhale njira yabwino yodziwira matenda, koma palibe kusiyana pakati pa ntchito ndi kujambula zithunzi ndi njira zina, kuchuluka kwa mavuto omwe amabwera pambuyo pa opaleshoni ndi kofanana, ndipo kuchepa kwake kumatayika pakukhazikitsa kwakunja, kukhazikitsa waya wa percutaneous Kirschner, ndi kukhazikitsa plaster, matenda opatsirana ndi singano ndi ofala kwambiri; ndipo mavuto a tendon extensor ndi ofala kwambiri m'magawo okhazikitsa plate a distal radius. Kwa odwala omwe ali ndi matenda a osteoporosis, volar plate ndiyo chisankho choyamba.
Nthawi yotumizira: Disembala-12-2022
