掌侧万向锁定板治疗桡骨C3型骨折的临床分析
Clinical Analysis of Volar Universal Locking Plate in the Treatment of Type C3 Radial Fractures

作者: 宋坤修 , 庞波涛 , 徐 倩 , 高 玲 , 徐 娟 :滨州医学院附属医院手(显微)外科,山东 滨州;

关键词: 桡骨远端骨折掌侧万向锁定钢板内固定Distal Radius Fracture Volar Universal Locking Plate Internal Fixation

摘要: 目的:研究桡骨远端C3型骨折行掌侧万向锁定钢板固定的临床疗效。方法:我院自2016年7月到2019年10月,有38例桡骨远端C3型骨折,均自掌侧入路采用掌侧万向锁定钢板固定。末次随访采用Jakim评分标准评定腕关节功能。结果:38例均获得随访,随访时间4~36个月。复查X线片显示骨折均愈合,关节面恢复平整,掌倾角、尺偏角及桡骨高度恢复正常。术后无骨折畸形愈合及不愈合、钢板螺钉松动或断裂等并发症发生。末次随访时腕关节功能按Jakim评分标准评定:优26例,良10例,可2例,优良率94.7%。结论:对桡骨远端C3型骨折,采用掌侧入路行掌侧万向锁定钢板固定可取得满意的疗效,术中骨折可获得牢固的固定,患者可早期进行功能锻炼。

Abstract: Purpose: To study the clinical effect of volar universal locking plate fixation for type C3 fractures of the distal radius. Methods: From July 2016 to October 2019, 38 cases of C3 type fractures of distal radius were treated by volar universal locking plate. The wrist function was evaluated by Jakim Score Standard at the last follow-up. Results: All 38 cases were followed up (4~36 months). The x-ray showed that all the fractures healed, the articular surface was flattened, the palm inclination angle, ulnar deviation angle and radius height returned to normal. There were no postoperative complications such as malunion or nonunion, plate and screw loosening or fracture. At the last follow-up, wrist function was evaluated according to Jakim score: excellent in 26 cases, good in 10 cases, good in 2 cases, excellent and good in 94.7%. Conclusion: For type C3 fractures of the distal radius, volar universal locking plate fixation through volar approach is effective, stable fixation can be achieved, and patients can perform early functional exercises.

1. 引言

桡骨远端骨折是上肢骨折最常见的类型之一,大概占的17%。其中C3型的处理最困难(图1图2),虽然大部分可通过手法复位后石膏或夹板外固定,但仍存在骨折不稳定、桡骨的高度及关节面不易恢复、骨折再次移位及长时间外固定导致关节僵硬等问题。目前临床上有各种处理方式,如经皮穿针内固定 [1]、钢板内固定、克氏针或钢板合并外固定架 [2]、关节镜辅助内固定技术 [3] 等。我科自2016年7月到2019年10月,有38例桡骨远端C3型骨折采用掌侧万向锁定钢板固定,取得了满意的疗效。

2. 资料和方法

2.1. 一般资料

纳入标准:1) 受伤前腕关节功能基本正常;2) 不合并腕关节风湿性或类风湿性关节炎等疾病;3)术前经X片及CT检查诊断为桡骨远端C3型骨折。共纳入38例,其中男16例,女22例;年龄24~78岁。均采用掌侧切开复位万向锁定钢板内固定的方式。

2.2. 手术方法

手术均由同一组医生完成。臂神经丛阻滞麻醉后,采用掌侧Henry入路 [4],自桡侧腕屈肌腱与桡动静脉之间锐性分离,向尺侧牵开拇长屈肌,显露旋前方肌。自旋前方肌桡侧缘切开,保留少量腱性组织用于术后缝合 [5]。充分显露桡骨远端骨折端后,根据骨折移位情况行手法复位,首先自桡骨茎突处为进针点,打入1枚1.5 mm克氏针临时固定。经C臂透视见骨折复位后,放置1枚掌侧万向锁定钢板。用2枚1.0 mm克氏针分别自钢板近端及远端克氏针固定孔打入临时固定(可有效防止置入滑动孔普通螺钉时钢板向近端滑动)。再次透视确定钢板位置及远端克氏针与关节面的关系。先自近端滑动孔置入1枚普通螺钉使钢板与桡骨远端更加贴合。根据远端克氏针与关节面的关系,来调整远排万向螺钉的方向。术中可逐步透视避免螺钉突出背侧皮质或进入关节。透视侧位时需将腕部垫高,约22˚~25˚,以抵消尺偏角,可清楚得看到螺钉与关节面的关系(图3)。必要时加透腕掌屈切线位,以明确螺钉是否突破桡骨背侧皮质 [6]。透视确认骨折复位及钢板、螺钉位置满意后,拔除临时固定用的克氏针,缝合旋前方肌覆盖钢板,缝合刀口。

Figure 1. Anterolateral position of preoperative radiograph

图1. 术前X片正侧位

Figure 2. PRE-OP CT SCAN

图2. 术前CT扫描情况

Figure 3. Intraoperative anterior position and lateral tangent position

图3. 术中正位和侧切线位

2.3. 术后处理

术后根据患者疼痛情况可应用消炎止痛药物处理,术后2天内去除引流,刀口疼痛减轻即开始行手指屈伸活动锻炼。1周内开始腕关节的主动掌屈及背伸活动,并逐渐加大屈伸活动的幅度,以轻度疼痛为原则(图4)。然后进行腕关节旋转功能锻炼。

3. 结果

所有患者的手术切口均一期愈合。38例患者均获得随访,随访时间为术后4~36个月。复查X线片显示骨折均骨性愈合,关节面平整,掌倾角、尺偏角及桡骨高度基本恢复正常。无骨折畸形愈合及不愈合,螺钉无松动或断裂等并发症发生。应用Jakim评分标准 [7] (表1)进行功能评分,评分结果为:优26例,良10例,可2例,优良率94.7%。

Table 1. Jakim scoring criteria

表1. Jakim评分标准

Figure 4. The function of the patient recovered well after operation

图4. 患者术后功能恢复良好

Figure 5. Postoperative reexamination of Standard X-ray anteroposterior position was of no significance in judging the relationship between the screw and the articular surface

图5. 术后复查标准X片正侧位对判断螺钉与关节面关系毫无意义

Figure 6. CT SCAN showed that the articular surface was smooth and the position of plate and screw was satisfactory

图6. 术后复查CT见关节面平整,钢板及螺钉位置满意

4. 讨论

目前桡骨远端骨折的治疗方法较多,切开复位锁定钢板内固定是当前主流方式 [8],自掌侧入路,有很大的优势 [4]。万向螺钉可在不同的平面固定,获得较大的把持力,有利于骨折远端的复位维持,早期功能锻炼不容易导致内固定失效 [9]。在C3型骨折,特别是极远端骨折,因需要远排螺钉支撑关节面,其螺钉方向较难把握,不小心就容易进入腕关节内。术中被动活动腕关节,看腕关节活动度及有无摩擦感这种方式,对判断螺钉是否进入腕关节毫无意义,作者门诊曾遇到过两例此类情况。所以术中透视体位尤其重要,正常腕关节侧位对判断螺钉位置无意义(图5图6),术中透视侧位时采用切线位,包括斜侧位及腕掌屈切线位 [6]。将腕部抬高22˚~25˚的体位,抵消了尺偏角,可判断螺钉与关节面的关系,并且可显示关节面的复位情况。对于背侧骨折块,因为完整的背侧关节囊和骨膜有利于复位后骨块位置的维持和提供完整的物理包裹 [10],我们很少切开,可采用Kapandji技术(图3(B))将其复位固定。术后3周左右即可拔克氏针。早期进行功能锻炼,可获得良好的功能恢复。

NOTES

*通讯作者。

文章引用: 宋坤修 , 庞波涛 , 徐 倩 , 高 玲 , 徐 娟 (2020) 掌侧万向锁定板治疗桡骨C3型骨折的临床分析。 外科, 9, 65-70. doi: 10.12677/HJS.2020.93010

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