Parizvino kugadzirisa kwemukati kwe distal radius fractures, kune akasiyana anatomical locking plate masisitimu anoshandiswa mukiriniki.Aya magadzirirwo emukati anopa mhinduro iri nani kune mamwe marudzi akaoma ekutyoka, uye neimwe nzira anowedzera zviratidzo zvekuvhiyiwa kwekusagadzikana distal radius fractures, kunyanya avo vane osteoporosis.Muzvinafundo Jupiter anobva kuMassachusetts General Hospital nevamwe vakaburitsa nhevedzano yezvinyorwa muJBJS pane zvavakawana pakuvhara ndiro yekumisikidza distal radius fractures uye hunyanzvi hwekuvhiya hunoenderana.Ichi chinyorwa chinotarisa nzira yekuvhiya yekugadzirisa distal radius fractures yakavakirwa pakugadzirisa kwemukati kweiyo chaiyo fracture block.
Kuvhiya Techniques
Iyo yetatu-column theory, yakavakirwa pabiomechanical uye anatomical maitiro eiyo distal ulnar radius, ndiyo hwaro hwekusimudzira uye kukiriniki kushandiswa kweiyo 2.4mm plate system.Kupatsanurwa kwemakoramu matatu kunoratidzwa muMufananidzo 1.
Fig. 1 Matatu-column dzidziso ye distal ulnar radius.
The lateral column ndiyo lateral hafu ye distal radius, kusanganisira navicular fossa uye radial tuberosity, iyo inotsigira carpal mapfupa padivi reradial uye ndiko kwakabva mamwe marunda anodzikamisa wrist.
Koramu yepakati ndiyo hafu yepakati yeradius uye inosanganisira lunate fossa (yakabatana nemwedzi) uye sigmoid notch (yakabatana neiyo distal ulna) pane articular surface.Inowanzo kutakurwa, mutoro unobva ku lunate fossa unoendeswa kune radius kuburikidza ne lunate fossa.Ulnar lateral column, iyo inosanganisira distal ulna, triangular fibrocartilage, uye yakaderera ulnar-radial joint, inotakura mitoro kubva kumapfupa emapfupa emapfupa pamwe nekubva kune yakaderera ulnar-radial joint uye ine simba rekudzikamisa.
Nzira yacho inoitwa pasi pe brachial plexus anesthesia uye intraoperative C-arm X-ray imaging inokosha.Mutsinga wemishonga inorwisa mabhakitiriya yaipiwa anenge maminitsi makumi matatu isati yatanga nzira uye pneumatic tourniquet yakashandiswa kuderedza kubuda ropa.
Palmar plate fixation
Kune dzakawanda dzakaputsika, nzira yepalmar inogona kushandiswa kuona pakati pe radial carpal flexor uye radial artery.Mushure mekuziva uye kudzoreredza iyo flexor carpi radialis longus, iyo yakadzika pamusoro peiyo pronator teres tsandanyama inoonekwa uye iyo "L" yakaumbwa kupatsanurwa inosimudzwa.Mune mamwe mafractures akaoma, iyo brachioradialis tendon inogona kusunungurwa zvakare kuti iite kuti kuderedzwa kwekuputsika.
Pini yeKirschner inopinzwa mu radial carpal joint, iyo inobatsira kutsanangura distal-yakawanda miganhu yeradius.Kana chidimbu chidiki chekutyoka pamucheto wearticular chiripo, palmar 2.4mm simbi ndiro inogona kuiswa pamusoro peiyo distal articular margin yeradius yekugadzirisa.Nemamwe manzwi, kutsemuka kudiki kuzere pamusoro pemwedzi wemwedzi kunogona kutsigirwa nendiro ye 2.4mm "L" kana "T", sezvakaratidzwa mumufananidzo 2.
Kune dorsally displaced extra-articular fractures, zvinobatsira kucherechedza zvinotevera pfungwa.Chekutanga, zvakakosha kumisazve pakatyoka kwenguva pfupi kuti uve nechokwadi chekuti hapana matishu akapfava akaiswa mumagumo ekutyoka.Chechipiri, muvarwere vasina osteoporosis, kuputsika kunogona kuderedzwa nerubatsiro rwendiro: kutanga, chivharo chekuvhara chinoiswa pamucheto wepalmar anatomical plate, iyo yakachengetedzwa kune yakadzingwa distal fracture segment, ipapo distal uye. proximal fracture segments inoderedzwa nerubatsiro rweplate, uye pakupedzisira, mamwe screws anoiswa proximally.
FIGURE 3 Kuwedzera-articular kuputsika kweiyo dorsally displaced distal radius yakaderedzwa uye inogadziriswa kuburikidza nepalmar nzira.MUFANANIDZO 3-A Mushure mekupedzwa kwekuratidzwa kuburikidza neradial carpal flexor uye radial artery, pini yakatsetseka yeKirschner inoiswa mujoini ye carpal.Mufananidzo 3-B Manipulation of the displaced metacarpal cortex kuti igadzirise patsva.
Mufananidzo 3-C uye Mufananidzo 3-DA yakatsetseka Kirschner pini inoiswa kubva kune radial stem kuburikidza nemutsara wekutsemuka kuti ugadzirise kwechinguva kupera kwekuputsika.
Mufananidzo 3-E Kuonekwa kwakakwana kwebasa rekushanda kunowanikwa nekushandisa retractor isati yaiswa ndiro.MUFANANIDZO 3-F Distal row yekuvhara screws inoiswa padyo ne subchondral bone pamagumo edhistal fold.
Mufananidzo 3-G X-ray fluoroscopy inofanira kushandiswa kusimbisa nzvimbo yeplate uye distal screws.Mufananidzo 3-H The proximal chikamu cheplate inofanira kunge ine imwe clearance (10 degree angle) kubva ku diaphysis kuitira kuti ndiro inogona kuiswa kune diaphysis kuti iwedzere kugadzirisa distal fracture block.Mufananidzo 3-I Simbisa iyo proximal sikuruu kuti udzorere kurerekera kwepalmar ye distal fracture.Bvisa pini yeKirschner isati yanyatsosimbiswa.
Zvifananidzo 3-J uye 3-K Intraoperative radiographic mifananidzo inosimbisa kuti kuputsika kwakapedzisira kwaiswa panzvimbo yeanatomi uye mapuranga eplate akaiswa zvinogutsa.
Dorsal Plate Fixation Iyo yekuvhiya nzira yekufumura iyo dorsal chikamu cheiyo distal radius inoenderana zvakanyanya nerudzi rwekutsemuka, uye kana pakatyoka ine maviri kana anopfuura intra-articular fracture zvidimbu, chinangwa chekurapa ndechekugadzirisa zvese zviri zviviri. iyo radial uye mbiru dzepakati panguva imwe chete.Intraoperatively, mabhendi ekutsigira ekuwedzera anofanirwa kuve akaiswa munzira mbiri huru: kwenguva refu mu2nd uye 3rd extensor compartments, ine subperiosteal dissection kune 4th extensor compartment uye kudzoreredzwa kweiyo tendon inoenderana;kana yechipiri rutsigiro bhendi incision pakati 4th uye 5th extensor compartments kufumura mbiru mbiri zvakasiyana (Fig. 4).
Kutyoka kunoshandiswa uye kunogadziriswa kwenguva pfupi nepini isina kuverengwa yeKirschner, uye mifananidzo yeradiographic inotorwa kuti ione kuti kuputsika kwakanyatsotamiswa.Tevere, iyo dorsal ulnar (yepakati column) divi reradius inodzikamiswa ne 2.4 mm "L" kana "T" ndiro.Iyo dorsal ulnar plate yakaumbwa kuti ive nechokwadi chekusimba padivi remushure ulnar yedhidhiyo.Mahwendefa anogonawo kuiswa padyo neiyo dorsal aspect ye distal lunate sezvinobvira, sezvo grooves inoenderana nechepasi pendiro yega yega inobvumira mahwendefa kuti akotama uye kuumbwa pasina kukuvadza tambo mumaburi eku screw (Fig. 5) .
Kugadziriswa kweiyo radial column plate iri nyore, sezvo bhonzo repamusoro pakati pekutanga neyechipiri extensor compartments rinenge rakati sandarara uye rinogona kugadzikwa munzvimbo iyi nendiro yakanyatsoumbwa.Kana iyo Kirschner pini yakaiswa munzvimbo yakanyanyisa distal ye radial tuberosity, iyo distal end of radial column plate ine groove inoenderana neKirschner pin, iyo isingakanganise nzvimbo yeplate uye inochengetedza kuputsika panzvimbo. (Mufananidzo 6).
Fig. 4 Kuratidzwa kweiyo dorsal surface ye distal radius.Bhandi rekutsigira rinovhurwa kubva ku3rd extensor interosseous compartment uye extensor hallucis longus tendon inodzoserwa.
Fig. 5 Kugadziriswa kwechidimbu chechidimbu che articular surface ye lunate, dorsal "T" kana "L" ndiro inowanzoumbwa (Fig. 5-A uye Fig. 5-B).Kana iyo dorsal plate pane articular pamusoro pemwedzi yakachengetedzwa, radial column plate inochengetedzwa (Figure 5-C kusvika 5-F).Mahwendefa maviri akaiswa pamakona e70 degrees kune mumwe nemumwe kuti avandudze kugadzikana kwekugadzirisa kwemukati.
Fig. 6 Radial column plate yakanyatsogadzirwa uye yakaiswa mumutsara we radial, ichicherechedza notch pamagumo eplate, iyo inobvumira ndiro kuti irege kudzivirira kwechinguva chepini yeKirschner pasina kupindira nechinzvimbo cheplate.
Pfungwa dzakakosha
Zviratidzo zveMetacarpal Plate Fixation
Yakabviswa metacarpal intra-articular fractures (Barton fractures)
displaced extra-articular fractures (Colles naSmith fractures).Kugadziriswa kwakagadzikana kunogona kuwanikwa ne screw plates kunyangwe pamberi pe osteoporosis.
Displaced metacarpal lunate articular surface fractures
Zviratidzo zvekugadzirisa dorsal plate
Nekukuvara kwe intercarpal ligament
Displaced dorsal lunate joint surface fracture
Dorsally sheared radial carpal joint fracture dislocation
Contraindications kune palmar plate fixation
Yakanyanya osteoporosis ine zvakakosha kushanda zvisingakwanisi
Dorsal radial wrist fracture dislocation
Kuvapo kwezvizhinji zvekurapa comorbidities
Contraindications kune dorsal plate fixation
Multiple medical comorbidities
Non-displaced fractures
Zvikanganiso zvakaitwa nyore mupalmar plate fixation
Nzvimbo yeplate yakakosha nekuti kwete chete kuti ndiro inotsigira kutsemuka kukuru, asi kumira kwakakodzera kunodzivirira distal locking screw kubva pakupinda mu radial carpal joint.Kungwarira intraoperative radiographs, inofungidzirwa nenzira imwechete seye radial inclination ye distal radius, inobvumira kunyatsoona kwearticular pamusoro peradial side ye distal radius, iyo inogona zvakare kunyatsoonekwa zvakanyanya nekuisa iyo ulnar screws kutanga panguva kushanda.
Kupinda mukati meiyo dorsal cortex kunotakura njodzi yekutsamwisa iyo tendon extensor uye kukonzera tendon kuputika.Locking screws anoita zvakasiyana kubva kune akajairwa screws, uye hazvifanirwe kupinda mudorsal cortex nema screws.
Zvikanganiso zvinogadzirwa nyore nedorsal plate fixation
Pane nguva dzose njodzi yekupinza screw mu radial carpal joint, uye zvakafanana nenzira inotsanangurwa pamusoro apa maererano nepalmar plate, pfuti ye oblique inofanira kutorwa kuti ione kana nzvimbo ye screw yakachengeteka.
Kana kugadzirisa kweiyo radial column kukaitwa kutanga, screws mu radial tuberosity inozokanganisa kuongororwa kweinotevera kugadzirisa kweiyo articular surface resurfacing ye lunate.
Distal screws iyo isina kupetwa zvachose mugomba rekupura inogona kukanganisa tendon kana kutokonzera kuputika kwetendon.
Nguva yekutumira: Zvita-28-2023
