Pakali pano, pali njira zosiyanasiyana zochizira fractures distal utali wozungulira, monga pulasitala fixation, kuchepetsa lotseguka ndi fixation mkati, chimango fixation kunja, etc. Pakati pawo, volar mbale fixation angapeze zotsatira zogwira mtima, koma pali malipoti m'mabuku. kuti zovuta zake ndizokwera mpaka 16%.Komabe, ngati mbale yachitsulo imasankhidwa bwino, zochitika zazovuta zimatha kuchepetsedwa bwino.Pepalali likufotokoza mwachidule mawonekedwe, zisonyezo, zotsutsana, ndi njira zopangira opaleshoni ya volar plate treatment ya distal radius fractures.
1. Pali zabwino ziwiri zazikulu za mbale ya kanjedza
A. Ikhoza kusokoneza gawo la mphamvu ya buckling.Kukonzekera ndi zomangira za angled kumathandizira chidutswa cha distal ndikusamutsira katundu ku radial shaft (mkuyu 1).Ikhoza kupeza chithandizo cha subchondral bwino.Dongosolo la mbale iyi silingangokhazika mtima pansi ma distal intra-articular fractures, komanso limatha kubwezeretsanso bwino mawonekedwe a intra-articular subchondral bone kudzera pa msomali / screw "mawonekedwe a fan".Kwa mitundu yambiri ya distal radius fracture, dongosolo la denga ili limapereka kukhazikika kowonjezereka kulola kusonkhanitsa koyambirira.
Chithunzi 1, a, pambuyo pa kumangidwanso kwa mbali zitatu za kuphwanyidwa kwakutali kwakutali, kulabadira kuchuluka kwa kupsinjika kwapakhosi;b, kuchepa kwapang'onopang'ono, cholakwikacho chiyenera kukhazikitsidwa ndikuthandizidwa ndi mbale;c, lateral view pambuyo DVR fixation, muvi limasonyeza katundu kusamutsa.
B. Kusakhudzidwa kochepa pa minofu yofewa: Kukhazikika kwa mbale ya volar kumakhala pansi pang'ono pa mzere wa madzi, poyerekeza ndi mbale ya dorsal, ikhoza kuchepetsa kukwiyitsa kwa tendon, ndipo pali malo ambiri omwe amapezeka, omwe amatha kupeŵa bwino kuyika ndi tendon.kukhudzana mwachindunji.Kuphatikiza apo, ma implants ambiri amatha kuphimbidwa ndi pronator quadratus.
2. Zizindikiro ndi contraindications zochizira distal utali wozungulira ndi volar mbale
Zizindikiro: Pakulephera kwa kuchepetsa kutsekedwa kwa ma fractures owonjezera, zotsatirazi zimachitika, monga kupweteka kwa dorsal kuposa 20 °, kuponderezana kwa dorsal kuposa 5mm, kufupikitsa kwakutali kuposa 3mm, ndi distal fragment displacement yaikulu kuposa 2 mm;Kusamuka kwa fracture yamkati ndi yayikulu kuposa 2 mm;chifukwa cha kuchepa kwa mafupa, n'zosavuta kuyambitsanso kusamuka, choncho ndizoyenera kwambiri kwa okalamba.
b.Contraindications: ntchito m`deralo mankhwala ochititsa, m`deralo kapena zokhudza zonse matenda opatsirana, osauka khungu pa volar mbali ya dzanja;fupa la mafupa ndi mtundu wa fracture pa malo ophwanyika, mtundu wa fracture wa dorsal monga Barton fracture, radiocarpal joint fracture and dislocation, simple radius Styloid process fracture, avulsion avulsion fracture of volar margin.
Kwa odwala omwe ali ndi kuvulala kwamphamvu kwambiri monga kuphulika kwakukulu kwa intra-articular comminuted fractures kapena kuwonongeka kwakukulu kwa fupa, akatswiri ambiri samalimbikitsa kugwiritsa ntchito mbale za volar, chifukwa fractures zoterezo zimakhala zovuta ku vascular necrosis ndipo zimakhala zovuta kupeza kuchepa kwa anatomical.Kwa odwala omwe ali ndi tiziduswa tambirimbiri komanso kusamuka kwakukulu komanso kufooka kwa mafupa, volar plate ndiyovuta kuti ikhale yothandiza.Pakhoza kukhala mavuto ndi chithandizo cha subchondral mu distal fractures, monga kulowetsa phula muzitsulo zolumikizana.Zolemba zaposachedwa zinanena kuti pamene milandu ya 42 ya fractures ya intra-articular inagwiritsidwa ntchito ndi mbale za volar, palibe zomangira zamkati zomwe zinalowa m'kati mwa articular, zomwe zinali zogwirizana kwambiri ndi malo a mbale.
3. Luso la opaleshoni
Madokotala ambiri amagwiritsa ntchito volar plate fixation kwa distal radius fractures m'njira ndi njira zofanana.Komabe, kuti mupewe kuopsa kwa zovuta zomwe zimachitika pambuyo pa opaleshoni, njira yopangira opaleshoni yapamwamba imafunika, mwachitsanzo, kuchepetsako kungapezeke mwa kumasula kupanikizika kwa fracture block ndikubwezeretsa kupitiriza kwa fupa la cortical.Kukonzekera kwakanthawi ndi mawaya a 2-3 Kirschner angagwiritsidwe ntchito.Ponena za njira yogwiritsira ntchito, wolembayo amalimbikitsa PCR (flexor carpi radialis) kuti awonjezere njira ya volar.
a, Kukonzekera kwakanthawi ndi mawaya awiri a Kirschner, zindikirani kuti mawonekedwe a volar ndi articular surface sakubwezeretsedwa kwathunthu panthawiyi;
b, Waya wa Kirschner amakonza mbale kwakanthawi, tcherani khutu pakukhazikika kwa malekezero akutali a radius panthawiyi (njira yokhazikika ya distal fragment fixation), mbali yoyandikira ya mbaleyo imakokedwa kumtunda wa radial kuti abwezeretse kupendekera kwa volar. .
C, Pamwamba pake amawunikiridwa bwino pansi pa arthroscopy, zotsekera / pini ya distal imayikidwa, ndipo utali wozungulira umachepetsedwa ndikukhazikika.
Mfundo zazikuluzikuluya kuyandikila: Kudulidwa kwa khungu lakutali kumayambira pakhungu la dzanja, ndipo kutalika kwake kungadziwike molingana ndi mtundu wa fracture.The flexor carpi radialis tendon ndi m'chimake wake ndi dissected distal ku carpal fupa ndi moyandikana monga n'kotheka.Kukoka flexor carpi radialis tendon kumbali ya ulnar kumateteza mitsempha yapakati ndi flexor tendon complex.Malo a Parona akuwonekera, ndi pronator quadratus yomwe ili pakati pa flexor hallucis longus (ulnar) ndi radial artery (radial).Kudulira kunapangidwa pa mbali yozungulira ya pronator quadratus, kusiya gawo lomwe limalumikizidwa ndi radius kuti amangenso pambuyo pake.Kukokera pronator quadratus ku mbali ya ulnar kumawonetsa bwino mbali ya volar ulnar ya radius.
Kwa mitundu yovuta yothyoka, tikulimbikitsidwa kumasula kuyika kwa distal kwa minofu ya brachioradialis, yomwe ingachepetse kukoka kwake pa ndondomeko ya radial styloid.Panthawiyi, volar sheath ya chipinda choyamba cha dorsal chikhoza kudulidwa kuti chiwonetsere kuphulika kwa distal Kutchinga mbali ya radial ndi radial styloid ndondomeko, mkati mozungulira tsinde lozungulira kuti lilekanitse ndi malo ophwanyika, ndiyeno gwiritsani ntchito mawaya a Kirschner kuti muchepetse intra. - articular fracture chipika.Kwa fractures yovuta ya intra-articular, arthroscopy ingagwiritsidwe ntchito kuthandizira kuchepetsa, kuyesa, ndi kukonza bwino zidutswa za fracture.
Pambuyo kuchepetsa kutsirizidwa, mbale ya volar imayikidwa nthawi zonse.Mbaleyo iyenera kukhala pafupi ndi madzi, iyenera kuphimba ndondomeko ya ulnar, ndipo mapeto oyandikira a mbale ayenera kufika pakatikati pa shaft yozungulira.Ngati zomwe zili pamwambazi sizinakwaniritsidwe, kukula kwa mbale sikuli koyenera, kapena kuchepetsa sikokwanira, ntchitoyo siinali yangwiro.
Zovuta zambiri zimakhala ndi zambiri zokhudzana ndi komwe mbale imayikidwa.Ngati mbaleyo imayikidwa mozungulira kwambiri, zovuta zokhudzana ndi flexor hallucis longus zimapangidwira;ngati mbaleyo imayikidwa pafupi kwambiri ndi mzere wamadzi, flexor digitorum profundus ikhoza kukhala pangozi.Kuchepa kwa fracture kwa volar displacement deformity kungapangitse kuti mbale yachitsulo ipite kumbali ya volar ndikulumikizana mwachindunji ndi flexor tendon, pamapeto pake imatsogolera ku tendonitis kapena ngakhale kupasuka.
Kwa odwala osteoporosis, tikulimbikitsidwa kuti mbaleyo ikhale pafupi ndi mzere wamadzi momwe mungathere, koma osati kudutsa..Mawaya a Kirschner angagwiritsidwe ntchito kukonza subchondral yomwe ili pafupi kwambiri ndi ulna, ndipo mawaya a Kirschner mbali ndi mbali ndi misomali yotseka ndi zomangira zimatha kuteteza bwino kuti fracture isasunthidwe.
Pambuyo poyikidwa bwino mbaleyo, mapeto a proximal amaikidwa ndi screw, ndipo dzenje la ulnar kumapeto kwa mbaleyo limakonzedwa kwakanthawi ndi waya wa Kirschner.Intraoperative fluoroscopy anteroposterior view, lateral view, wrist joint elevation 30 ° lateral view, kuti adziwe kuchepetsa fracture ndi malo okhazikika mkati.Ngati malo a mbale ndi okhutiritsa, koma waya wa Kirschner ali mu mgwirizano, zidzatsogolera kuchira kosakwanira kwa volar, zomwe zingathe kuthetsedwa mwa kubwezeretsanso mbale kudzera mu "njira yokhazikika ya distal fracture" (Mkuyu 2). b).
Ngati ikuphatikizidwa ndi kuphulika kwa dorsal ndi ulnar (ulnar / dorsal Die Punch) ndipo sikungathe kuchepetsedwa mokwanira kutsekedwa, njira zitatu zotsatirazi zingagwiritsidwe ntchito:
1. Tembenuzirani kumapeto kwa radius kuti isakhale kutali ndi malo ophwanyika, ndikukankhira kuphulika kwa mwezi kumtunda wa carpus kupyolera mu njira yowonjezera ya PCR;
2. Pangani kang'ono kakang'ono kumbali ya dorsal ya 4th ndi 5th compartment kuti muwonetsere chidutswa chophwanyika, ndikuchikonza ndi zomangira mu dzenje la ulnar la mbale.
3. Kutsekedwa kwa percutaneous kapena pang'onopang'ono kumangiriza mothandizidwa ndi arthroscopy.
Pambuyo pakuchepetsako kumakhala kokhutiritsa ndipo mbaleyo imayikidwa molondola, kukonza komaliza kumakhala kosavuta.Ngati waya wa ulnar wa Kirschner wakhazikika bwino ndipo palibe zomangira zomwe zili mumphako, kuchepetsedwa kwa thupi kumatha kupezeka.
Chochitika chosankha screw: Chifukwa cha comminution kwambiri ya dorsal cortical bone, kutalika kwa screw kungakhale kovuta kuyeza molondola.Zomangira zomwe zimakhala zazitali kwambiri zimatha kuyambitsa kukwiya kwa tendon, ndipo zomangira zomwe zimakhala zazifupi kwambiri sizingathandizire ndikukonza chidutswa cha dorsal.Pazifukwa izi, wolemba amalimbikitsa kugwiritsa ntchito zomangira zokhoma zomata ndi zomangira zotsekera zambiri munjira ya radial styloid ndi dzenje la ulnar, ndikugwiritsa ntchito zomangira zopukutira zotsekera m'malo ena onse.Kugwiritsira ntchito nsonga yosamveka kumapewa kukwiya kwa tendon ngakhale kutuluka kwa dorsal kumagwiritsidwa ntchito.Pakukhazikika kwa mbale zolumikizirana, zomangira ziwiri zolumikizirana + zomangira imodzi wamba (zoyikidwa kudzera pa ellipse) zitha kugwiritsidwa ntchito kukonza.
4. Chidule cha mawu onse:
Kukhazikika kwa volar kutsekeka kwa msomali wa distal radius fractures kumatha kukwaniritsa bwino zachipatala, zomwe zimatengera kusankha kwa zisonyezo ndi luso lapamwamba kwambiri la opaleshoni.Kugwiritsa ntchito njira imeneyi kungathe kupeza bwino matenda oyambirira a ntchito, koma palibe kusiyana pakati pa ntchito yamtsogolo ndi kujambula ndi njira zina, zochitika za zovuta za postoperative ndizofanana, ndipo kuchepetsa kumatayika mu fixation kunja, percutaneous Kirschner waya fixation, ndi pulasitala fixation. , matenda a singano amapezeka kwambiri;ndipo mavuto a tendon extensor amapezeka kwambiri mumayendedwe a distal plate fixation.Kwa odwala osteoporosis, volar plate akadali kusankha koyamba.
Nthawi yotumiza: Dec-12-2022
