Parizvino, kupwanyika kwechikamu chedistal radius kunorapwa nenzira dzakasiyana-siyana, dzakadai sekugadzirisa plaster, kuchekwa uye kuderedza kugadziriswa kwemukati, bracket yekubatanidza kunze, nezvimwewo. Pakati pazvo, kugadzirisa plate yepalmar kunogona kuwana mhedzisiro inogutsa, asi mamwe mabhuku anotaura kuti mwero wayo wekupwanyika wakakwira kusvika ku16%. Zvisinei, kana plate ikasarudzwa nemazvo, mwero wekupwanyika unogona kuderedzwa zvinobudirira. Pfupiso pfupi yemhando, zviratidzo uye nzira dzekuvhiya dzekupaka palmar pakukuvara kwechikamu chedistal radius inoratidzwa.
I. Mhando dze distal radius fractures
Kune nzira dzakasiyana-siyana dzekupatsanura mapfupa, kusanganisira Müller AO classification zvichibva pahunhu hwemuviri uye Femandez classification zvichibva pamaitiro ekukuvara. Pakati padzo, Eponymic classification inosanganisa zvakanakira zvikwata zvekare, inosanganisira mhando ina huru dzekupatsanura mapfupa, uye inosanganisira Maleon 4-part fractures uye Chaffer's fractures, izvo zvinogona kuva gwara rakanaka rebasa rekurapa.
1. Kurongwa kweMüller AO - kutyoka kwezvikamu mukati memutsipa
Kupatsanurwa kweAO kwakakodzera kupatsanurwa kwedivi redhiramu uye kunopatsanura kuita mhando nhatu huru: mhando A extra-articular, mhando B partial intra-articular, uye mhando C total joint fractures. Rudzi rumwe nerumwe runopatsanurwawo kuita musanganiswa wakasiyana wemapoka madiki zvichienderana nekuoma uye kuoma kwekutsemuka.
Rudzi A: Kutyoka kweExtra-articular
A1, kutyoka kwechiuno chemusana, radius sekukuvara (A1.1, kutyoka kwetsinde remusana; A1.2 kutyoka kuri nyore kwediaphysis yemusana; A1.3, kutyoka kwakachekwa kwediaphysis yemusana).
A2, Kutyoka kweradius, kuri nyore, nechikamu chiri mukati (A2.1, radius isina kutsveyama; A2.2, kurereka kweradius dorsal, kureva, kutyoka kwaPouteau-Colles; A2.3, kurereka kweradius palmar, kureva, kutyoka kwaGoyrand-Smith).
A3, Kutyoka kweradius, yakachekwa (A3.1, kupfupika kweradius; A3.2 chidimbu cheradius chakaita sewedge; A3.3, kutyoka kweradius kwakachekwa).
Rudzi B: kuputsika kwechikamu chechikamu
B1, kutyoka kweradius, sagittal plane (B1.1, lateral simple type; B1.2, lateral comminuted type; B1.3, medial type).
B2, Kutyoka kwemucheto wemupendero we radius, kureva, kutyoka kwaBarton (B2.1, mhando iri nyore; B2.2, kutyoka kwemupendero we ...
B3, Kutyoka kwemucheto we metacarpal we radius, kureva, kutyoka kwe anti-Barton, kana kutyoka kwerudzi rwechipiri rwaGoyrand-smith (B3.1, mutemo we femoral uri nyore, chidimbu chidiki; B3.2, kutyoka kuri nyore, chidimbu chikuru; B3.3, kutyoka kwakapfupikiswa).
Rudzi C: kuputsika kwese kwe articular
C1, kutyoka kwe radial kune mhando iri nyore yenzvimbo dzine articular ne metaphyseal (C1.1, kutyoka kwe posterior medial articular; C1.2, kutyoka kwe sagittal kwenzvimbo dzine articular; C1.3, kutyoka kwe coronal pamusoro pe articular).
C2, Kutyoka kwechikamu chepakati chechikamu, chikamu chiri nyore chemativi maviri, metaphysis yakakamurwa (C2.1, kutyoka kwechikamu chepakati chechikamu chepakati chechikamu chepakati chechikamu chepakati; C2.2, kutyoka kwechikamu chepakati chechikamu chepakati chechikamu chepakati chechikamu chepakati; C2.3, kutyoka kwechikamu chepakati kunopinda muchikamu chepakati chechikamu chepakati).
C3, kutyoka kwechikamu chepakati chemuviri, kutyoka kwechikamu chepakati (C3.1, kutyoka kuri nyore kwechimiro chemuviri; C3.2, kutyoka kwechikamu chepakati chemuviri; C3.3, kutyoka kwechikamu chepakati kunosvika pachikamu chepakati chemuviri).
2. Kupatsanurwa kwezvikamu zve distal radius.
Zvichienderana nemaitiro ekukuvara, Femandez inogona kukamurwa kuita mhando shanu:.
Kupwanyika kwerudzi rwekutanga (Type I fractures) kunonzi extra-articular metaphyseal comminuted fractures dzakadai seColles fractures (dorsal angulation) kana Smith fractures (metacarpal angulation). Chikamu chepfupa rimwe chinotyoka kana paine kushushikana uye contralateral cortex inobviswa uye inopinzwa.
Kutyoka
Kutyoka kwerudzi rwechitatu kunokonzerwa nekutyoka kwemapfupa mukati memuviri, kunokonzerwa nekuoma kwemapfupa. Kutyoka uku kunosanganisira kutyoka kwemapfupa epalmar Barton, kutyoka kwemapfupa emusana weBarton, uye kutyoka kwemapfupa emusana weradial.
Kushungurudzika kwekucheka
Kupwanyika kwerudzi rwechitatu kunonzi kupwanyika kwemukati memapfupa emuviri (intra-articular fractures) uye kupinza kwemasero emuviri (metaphyseal insertions) kunokonzerwa nekukuvara kwekumanikidzwa, kusanganisira kupwanyika kwakaoma kwemapfupa emuviri (complex articular fractures) uye kupwanyika kwepilon ye radial.
Kuisa
Kutyoka kwerudzi rwechina kutyoka kwe ligamentous attachment kunoitika panguva yekutyoka-kutyoka kwe radial carpal joint.
Kutyoka kweAvulsion I dislocation
Kutyoka kwerudzi rweV kunokonzerwa nekukuvara kwekukurumidza kunosanganisira masimba akawanda ekunze uye kukuvara kukuru. (Mixed I, II, III, IV)
3. Kunyora mazita eponymic
II. Kurapa kwekutyoka kwerutivi rwedivi nekushandisa plating yemichindwe
Zviratidzo.
Kune mapfupa akatyoka ari kunze kwearticular mushure mekukundikana kwekudzikira kwechiuno mumatambudziko anotevera.
Kutenderera kwepadumbu kupfuura 20°
Kudzvanywa kwepadumbu kwakakura kupfuura 5 mm
Kupfupika kweredhiyasi iri kure kupfuura 3 mm
Kufamba kwebhuroko rekutyoka kwedivi kupfuura 2 mm
Kune mapfupa emukati mearticular anopfuura 2mm kusuduruka
Nyanzvi zhinji hadzikurudzire kushandiswa kwemaplate emetacarpal pakukuvara kunowedzera simba, sekunge kutyoka kwakanyanya mukati mearticular comminute kana kurasikirwa kwakanyanya kwemapfupa, nekuti zvidimbu izvi zvekutyoka zviri kure zvinowanzobatwa ne avascular necrosis uye zvakaoma kuzvigadzirisa patsva.
Kune varwere vane zvidimbu zvakawanda zvemapfupa akatyoka uye kusuduruka kwakanyanya uye vane osteoporosis yakanyanya, metacarpal plating haishande. Kutsigira subchondral kwemafupa akatyoka kungave kunetsa, senge kupinda kwescrew mugomba remajoini.
Maitiro ekuvhiya
Vanachiremba vazhinji vanoshandisa nzira yakafanana uye nzira yekugadzirisa mapfupa akatyoka edivi redhiramu vachishandisa plate yemuchindwe. Zvisinei, nzira yakanaka yekuvhiya inodiwa kudzivirira matambudziko mushure mekuvhiyiwa, semuenzaniso, kuderedza kunogona kuwanikwa nekusunungura block yekutyoka kubva mukumanikidzwa kwakaiswa uye kudzoreredza kuenderera mberi kwebhonzo re cortical. Kugadziriswa kwenguva pfupi ne 2-3 Kirschner pins kunogona kushandiswa, nezvimwewo.
(I) Kugadzirisa chimiro chemuviri usati wavhiyiwa uye kumira zvakanaka
1. Kudhonza kunoitwa nenzira ye radial shaft uchishandisa fluoroscopy, chigunwe chikadzvanya proximal fracture block pasi kubva kurutivi rwepalmar uye zvimwe zvigunwe zvichisimudza distal block mudenga nekona kubva kurutivi rwedorsal.
2. Nzvimbo yakarara, gumbo rakakanganiswa riri patafura yeruoko pasi pe fluoroscopy.
(II) Nzvimbo dzekupinda.
Kuti pave nerudzi rwenzira inofanira kushandiswa, nzira yePCR (radial carpal flexor) extended palmar inokurudzirwa.
Kumucheto kweganda kunotangira paganda rakachekwa paruoko uye kureba kwaro kunogona kuonekwa zvichienderana nerudzi rwekutyoka kwaro.
Katsinga ke radial flexor carpi radialis ne tendon sheath yaro zvakachekwa, zviri kure nemapfupa e carpal uye zviri pedyo nerutivi rwe proximal sezvinobvira.
Kudhonza radial carpal flexor tendon kudivi reulnar kunodzivirira median nerve complex ne flexor tendon complex.
Nzvimbo yeParona inoonekwa uye tsandanyama ye anterior rotator ani iri pakati pe flexor digitorum longus (rutivi rwe ulnar) ne radial artery (rutivi rwe radial).
Cheka divi remusana we anterior rotator ani, uchiti chikamu chinofanira kusiiwa chakabatana ne radius kuti chizogadziriswazve gare gare.
Kudhonza tsandanyama ye anterior rotator ani kune rumwe rutivi rwe ulnar kunoita kuti nyanga ye ulnar ionekwe zvakanaka padivi re charmmar re radius.
Nzira yemuchindwe inoburitsa pachena nharaunda iri kure uye inonyatsoburitsa pachena kona yekumusoro.
Kune mhando dzakaoma dzekutyoka, zvinokurudzirwa kuti distal brachioradialis stop ikwanise kusunungurwa, izvo zvinogona kuderedza kudhonzwa kwayo pa radial tuberosity, ipapo panogona kuchekwa sheath yepalmar compartment yekutanga dorsal, iyo inogona kuburitsa distal fracture block radial ne radial tuberosity, ichitenderedza radius Yu mukati kuti ibvise panzvimbo yakatyoka, uye wobva wagadzirisa intra-articular fracture block uchishandisa Kirschner pin. Kune complex intra-articular fractures, arthroscopy inogona kushandiswa kubatsira mukuderedza, kuongorora uye kugadzirisa fracture block.
(III) Nzira dzekuderedza.
1. Shandisa pfupa senzira yekudzosera patsva
2. Mubatsiri anodhonza minwe yemurwere yemuromo neyepakati, izvo zvichave nyore kugadzirisa patsva.
3. Vhara pini yeKirschner kubva pa radial tuberosity kuti igadziriswe kwenguva pfupi.
Mushure mekunge nzvimbo yacho yapera, ndiro yemuti wepalmar inoiswa nguva dzose, iyo inofanira kunge iri pedyo nenzvimbo yemvura, inofanira kufukidza nzvimbo yekumusoro, uye inofanira kunge iri pedyo nepakati pemuti we radial. Kana mamiriro aya asina kuzadzikiswa, kana ndiro yacho isiri saizi yakakodzera, kana kuti nzvimbo yacho isingafadzi, maitiro acho haasati akwana.
Matambudziko mazhinji ane chekuita zvakanyanya nenzvimbo yeplate. Kana plate yacho yakaiswa kure zvakanyanya nedivi reradial, matambudziko ane chekuita ne bunion flexor anogona kuitika; kana plate yacho yakaiswa pedyo zvakanyanya newatershed line, flexor yakadzika yemunwe inogona kunge iri panjodzi. Kukanganisika kwekutyoka kwakaiswa panzvimbo yayo kudivi repalmar kunogona kukonzera kuti plate ibude kudivi repalmar uye ibatane zvakananga ne flexor tendon, zvichizoguma zvaita kuti tendonitis kana kutoputika.
Muvarwere vane osteoporosis, zvinokurudzirwa kuti ndiro yacho iiswe pedyo nemutsetse wemvura sezvinobvira, asi kwete pamusoro payo. Kugadzika kwe subchondral kunogona kuitwa uchishandisa mapini eKirschner ari pedyo neulna, uye mapini eKirschner ari padivi nepadivi uye masikuruu anokiya anoshanda kudzivirira kuputsika patsva.
Kana ndiro yaiswa zvakanaka, mugumo weproximal unogadziriswa nesikuruu imwe chete uye mugumo wekure weplate unogadziriswa kwenguva pfupi neKirschner pini mugomba repamusoro-soro. Kuongororwa kwe fluoroscopic orthopantomograms, maonero emativi, uye mafirimu emativi ane kukwirira kwemaoko kwe30° zvakatorwa kuti zvionekwe kuderedzwa kwekutyoka uye nzvimbo yekuisa mukati.
Kana ndiro yacho yakamira zvakanaka, asi pin yeKirschner iri mukati memusana, izvi zvinoguma nekusagona kudzoreredza kutsveyama kwemuchindwe, izvo zvinogona kugadziriswa nekuisazve ndiro yacho uchishandisa "distal fracture fixation technique" (Mufananidzo 2, b).
Mufananidzo 2.
a, mapini maviri eKirschner ekugadzirisa kwenguva pfupi, cherechedza kuti kutsveyama kwemetacarpal uye nzvimbo dzakabatana hazvina kudzorerwa zvakakwana panguva ino;
b, Pini imwe chete yeKirschner yekugadzirisa plate kwenguva pfupi, cherechedza kuti distal radius yakagadzika panzvimbo iyi (distal fracture block fixation technique), uye chikamu cheproximal cheplate chinodhonzwa kuenda ku radial stem kuti chidzorere angle yekutsvedza kwepalmar.
C, Kugadziriswa kweArthroscopy kwenzvimbo dzakaita searticular, kuiswa kwezvikushi/mapini ekukiya ari kure, uye kugadziriswa kwekupedzisira nekugadzirisa kweproximal radius.
Kana paine kutyoka kwemusana nepauro (ulnar/dorsal Die Punch), izvo zvisingagone kugadziriswa zvakanaka kana zvavharwa, nzira nhatu dzinotevera dzinogona kushandiswa.
Radius yeproximal inotenderedzwa nechemberi kubva panzvimbo yakatyoka, uye chivharo chekutyoka che lunate fossa chinosundirwa kumapfupa ecarpal kuburikidza nePCR lengthening approach; kucheka kudiki kunoitwa dorsal kusvika ku4th ne5th compartments kuti chivharo chekutyoka chionekwe, uye chinosungirirwa mu screw-fixed mu ulnar foramen yeplate. Kugadziriswa kwe percutaneous kana kuti zvishoma nezvishoma kwakaitwa nerubatsiro rwe arthroscopic.
Mushure mekugadziriswazve zvakanaka uye kuiswa zvakanaka kweplate, kugadziriswa kwekupedzisira kuri nyore uye kugadziriswazve kwemaumbirwo emuviri kunogona kuitwa kana proximal ulnar kernel pin yakaiswa zvakanaka uye pasina screws dziri mujointi (Mufananidzo 2).
(iv) Ruzivo rwekusarudza masikuruu.
Kureba kwezvikuro kunogona kuoma kuyera nemazvo nekuda kwekupwanyika kwakanyanya kwemapfupa emudumbu. Zvikuro zvakareba zvinogona kukonzera kuvhunduka kwetsinga uye kupfupika zvakanyanya kuti zvitsigire kugadzika kwekuvhara kwetsinga yemudumbu. Nekuda kwechikonzero ichi vanyori vanokurudzira kushandiswa kwezvikuro zvine tambo dzakasungwa uye zvikuro zvinosunga mutsinga dzakawanda mu radial tuberosity uye mu ulnar foramen yakawanda, uye kushandiswa kwezvikuro zvinosunga tsinga dzakatsvuka munzvimbo dzasara. Kushandisa musoro wakapfava kunodzivirira kuvhunduka kwetsinga kunyangwe kana yakaputirwa mudumbu. Pakugadzirisa plate yeproximal interlocking, zvikuro zviviri zvinosunga + sikuruu imwe chete (inoiswa kuburikidza ne ellipse) zvinogona kushandiswa kugadzirisa.
Dr Kiyohito vekuFrance vakapa ruzivo rwavo rwekushandisa maplate ekuvhara palmmar asinganyanyi kukuvadzwa pakutsemuka kwedivi redhiramu, uko kuchekwa kwavo kwakaderedzwa kusvika pa1cm yakanyanya, izvo zvinopesana. Nzira iyi inonyanya kuratidzwa pakutsemuka kwedivi redhiramu, uye zviratidzo zvayo zvekuvhiya ndezvekutsemuka kweAO fractions dzemhando A2 neA3 uye kutsemuka kwedivi redhiramu kwemhando C1 neC2, asi haina kukodzera kutsemuka kweC1 neC2 pamwe chete nekutsemuka kwemapfupa mukati medivi redhiramu. Nzira iyi haina kukodzerawo kutsemuka kwerudzi B. Vanyori vanotaurawo kuti kana kudzikiswa kwakanaka uye kugadziriswa kwenzvimbo iyi hakugoneke, zvinodikanwa kuti munhu achinje nzira yechinyakare yekuchekwa uye asanamatira kutsemuka kudiki kusinganyanyi kukuvadzwa.
Nguva yekutumira: Chikumi-26-2024
