桡骨远端骨折不同治疗方法临床疗效比较

[目的]探讨不同分型桡骨远端骨折的有效治疗方法.[方法]分析236例桡骨远端骨折的治疗,根据AO分型为A、B、C 3型,分别采用闭合手法复位中医小夹板外固定及石膏外固定、切开复位＂T＂形钢板内固定3种固定方法,分别进行骨折的复位评分、功能评分,并比较不同固定方法之间复位评分及功能评分优良率.[结果]236例病人术后均获随访,随访时间6～20个月,平均14.6个月.3组当中A、B型骨折复位评分优良率无显著性差别,功能评分小夹板外固定组及＂T＂形钢板内固定组优良率明显优于石膏外固定组,功能评分小夹板外固定组和＂T＂形钢板内固定组比较优良率无显著性差别;C组当中无论是复位评分还是功能评分,＂T＂形钢板内固定组优良率明显优于其它2组.[结论]对于C型骨折,建议行骨折切开复位内固定;对于A、B型骨折,闭合手法复位小夹板外固定能取得较好的临床疗效.     

T形钢板内固定治疗桡骨远端不稳定骨折

目的探讨T型钢板内固定治疗桡骨远端骨折的临床疗效。方法对按AO分类为B、C型的28例桡骨远端骨折患者,按A0内固定原则,使用斜“T”形或“T”形钢板行内固定治疗。结果术后随访4～18个月,平均12个月,所有患者均获得骨性愈合,根据术后X线片及改良Shea功能评估标准,优21例,良5例,可2例,优良率为93％。结论“T”形钢板治疗桡骨远端骨折临床疗效满意,尤其对于不稳定型以及骨质疏松性桡骨远端骨折,能够牢固维持术中恢复的解剖形状,有利于患腕早期功能锻炼。     

桡骨远端背侧粉碎骨折的T形钢板治疗

目的探讨切开复位背侧T形钢板内固定治疗背侧粉碎的桡骨远端骨折的疗效。方法对23例手法复位失败的背侧粉碎桡骨远端骨折行切开复位、T形钢板内固定,并随访其骨折愈合情况及远期功能效果。结果所有病例均获随访,平均随访时间为8．2个月（6～13个月）。所有骨折均获骨性愈合,愈合时间为52d（49～56d）,无伤口感染、骨不连、内固定断裂脱出、伸指受限等并发症。根据Colles骨折的改良Green and O’Brien临床评定标准综合评定,优17例,良6例。结论对于手法复位失败的背侧粉碎桡骨远端骨折,切开复位、背侧T形钢板内固定能获得满意的治疗效果。     

切开复位钢板内固定治疗桡骨远端B、C型骨折

目的探讨切开复位钢板内固定治疗桡骨远端B、C型骨折临床疗效。方法对76例AO分型桡骨远端B、C型骨折患者分别予以掌侧或背侧入路,切开复位AOT形钢板或锁定加压接骨板(LCP)内固定治疗。结果76例随访6~28个月,骨折全部愈合。根据改良McBride评分标准,49例腕关节75°(背伸)~75°(掌屈),17例70°(背伸)~54°(掌屈),7例腕关节伸屈活动无疼痛,3例诉有轻微疼痛。无腕关节旋转活动受限,优良率92.1%。结论采用切开复位钢板内固定治疗桡骨远端B、C型骨折,能有效恢复桡骨远端的解剖结构,使腕关节功能达到较好恢复。     

切开复位斜T形桡骨远端锁定钢板内固定治疗移位的锁骨外侧端骨折

目的探讨切开复位斜T形桡骨远端锁定钢板内固定治疗移位的锁骨外侧端骨折的临床疗效。方法对29例移位的锁骨外侧端骨折采用切开复位斜T形桡骨远端锁定钢板内固定治疗。结果29例获得随访6～18个月,骨折均愈合,平均愈合时间10—24周。疗效评定根据Hardegger等肩关节功能评定标准：优25例,良4例。结论移位的锁骨外侧端骨折采用切开复位斜T形桡骨远端锁定钢板内固定治疗可获得良好的l临床疗效,值得临床推广应用。     

三柱理论在C3型桡骨远端骨折手术治疗中的应用体会

目的探讨三柱理论在C3型桡骨远端骨折手术治疗中的指导意义及应用体会。方法根据腕关节三柱理论,采用切开复位T形钢板内固定联合外固定架治疗C3型桡骨远端骨折20例。结果 20例获6~20个月随访,X线片显示所有骨折达到骨性愈合,腕关节功能按Gartland-Werley评分:优16例,良3例,可1例。结论三柱理论可有效指导C3型桡骨远端骨折的手术治疗。     

掌侧T型钢板内固定治疗桡骨远端关节内骨折

内固定技术的发展使切开复位钢板内固定逐渐成为桡骨远端关节内骨折治疗的一种有效方法.我院2002年1月-2004年6月使用掌侧T型钢板内固定共治疗桡骨远端骨折24例,效果满意。     

掌侧锁定钢板治疗桡骨远端不稳定型骨折

目的探讨掌侧入路锁定钢板内固定治疗桡骨远端不稳定型骨折的临床疗效。方法对2006年8月至2011年12月我科收治的44例桡骨远端不稳定型骨折予以掌侧入路切开复位,以＂T＂形薄型桡骨远端锁定钢板内固定治疗。其中男19例,女25例;年龄21～69岁,平均54.4岁。根据桡骨远端骨折分型,B2型8例,B3型22例,C1型14例。结果 41例得到6～22个月随访,骨折全部愈合。根据Gartland和Werleg功能评分标准进行疗效评价,优35例,良4例,差2例,优良率95.1%。结论采用掌侧入路锁定钢板治疗桡骨远端不稳定型骨折,能有效维持骨折断端的复位,适应早期功能锻炼需要,疗效满意。     

钢板预置关节镜复位技术(PART)治疗桡骨远端骨折

目的 研究使用钢板预置关节镜复位技术(PART)治疗桡骨远端骨折,将腕掌侧锁定钢板技术与腕关节镜有效结合,提高C型桡骨远端骨折(AO分型)的治疗效果.方法 自2009年2月～2011年7月使用PART技术对13例桡骨远端C型骨折进行手术治疗,行桡骨远端骨折切开复位后予克氏针及预置掌侧锁定钢板临时固定骨折,在腕关节镜下对关节面处骨折行进一步复位,满意后用钢板螺钉将骨折完全固定.结果 桡骨远端关节面台阶移位及水平移位均在2 mm内.掌倾角0～15°,平均13.4°,尺偏角17～26°,平均22.3°.桡骨远端高度无短缩.采用Gartland和Werley评分标准对腕关节功能进行评价:优8例,良4例,中1例.结论 PART技术治疗桡骨远端C型骨折,将腕掌侧锁定钢板技术与腕关节镜有效简便结合,提高了关节面骨折复位水平,骨折固定坚强,可早期进行腕关节功能锻炼,临床效果优异.     

掌侧T型钢板内固定治疗桡骨远端关节内骨折

目的:探讨桡骨远端关节内骨折切开复位掌侧T型钢板内固定的临床疗效。方法:自2010年1月～2011年12月,对24例桡骨远端关节内骨折患者行掌侧入路T型钢板内固定,并进行随访。结果:24例患者均获随访,骨折愈合时间7～12周,平均为8周,疗效按Di enst功能评定标准评估,优16例,良6例,可2例,优良率为91.7%。结论:掌侧T型钢板治疗桡骨远端关节内骨折手术操作简单,固定牢靠,便于早期功能锻炼,是治疗桡骨远端关节内骨折的有效方法。     

掌侧和背侧钢板内固定治疗背侧不稳定性桡骨远端骨折的病例对照研究

目的:探讨两种不同手术入路内固定方法对背侧不稳定性桡骨远端骨折的疗效。方法:收集2006年8月至2010年10月采用手术切开复位钢板内固定治疗,并获得随访的病例47例。男21例,女26例;年龄39～73岁。所有患者分为2组:采用掌侧入路掌侧钢板内固定(A组)32例,锁定钢板27例,普通"T"形钢板5例,其中4例联合应用背侧克氏针内固定;采用背侧钢板内固定(B组)15例,其中锁定钢板7例,普通"T"形钢板8例。术后从腕关节功能、X线评分及并发症等方面对掌侧和背侧钢板2种固定方法的疗效进行比较。结果:掌侧和背侧钢板固定术后1周与术前比较,掌倾角、尺偏角及桡骨茎突高度均明显改善;2组术后1周与术后半年比较,掌倾角、尺偏角及桡骨茎突高度均无明显丢失。术后A组正中神经牵拉伤1例,切口感染1例,肌腱粘连2例;B组切口红肿感染1例,肌腱粘连1例,拇长伸肌腱刺激3例;掌侧钢板内固定并发症的发生率低于背侧钢板内固定。腕关节功能评价:A组优17例,良11例,可3例,差1例;B组优8例,良4例,可2例,差1例;掌侧钢板内固定与背侧钢板内固定疗效无明显差异。结论:背侧移位的桡骨远端不稳定骨折,采用掌侧入路掌侧钢板内固定同样可以达到良好的复位效果,而肌腱损害等并发症较背侧钢板固定更少。     

锁定加压接骨板治疗不稳定型桡骨远端粉碎性骨折

目的探讨不稳定型桡骨远端粉碎性骨折的治疗方法及效果。方法2007年2月-2011年1月根据桡骨远端骨折的类型分别采用掌侧入路、背侧入路及桡侧缘入路行切开复位加压锁定接骨板内固定或加植骨治疗不稳定型桡骨远端粉碎性骨折46例59侧,按照AO分型A2型4侧,A3型7侧,B1型3侧,B2型5侧,B3型10侧,C1型8侧,C2型13侧,C3型9侧。术中行植骨17侧。结果46例患者中41例49侧获5～28个月随访（平均14个月）,全部骨性愈合。腕关节功能按照改良McBride评分标准,优34侧,腕关节背伸750,掌曲-75°;良12侧,背伸70°,掌曲-54°;可3侧,腕关节屈伸有轻微痛,优良率92％。并发症包括背侧入路形成腱鞘炎4例,掌侧入路并发腕管综合征1例,均于拆除内固定后消失。结论复杂的不稳定型桡骨远端粉碎性骨折根据不同骨折类型采用不同的手术入路及支撑板内固定治疗可获得良好的腕关节功能恢复。     

锁定加压钢板在中青年桡骨远端关节内粉碎性骨折中的应用

目的 探讨中青年桡骨远端骨折的临床特点,及锁定加压钢板在桡骨远端关节内粉碎性骨折中的应用效果.方法 2008年2月到2010年6月,对25例桡骨远端关节内粉碎性骨折患者(20～50岁)进行切开复位LCP内固定,术后早期功能锻炼.结果 25例患者均获得随访,随访6～20个月,平均12个月.所有患者掌倾角、尺偏角、桡骨短缩程度、关节面台阶等均得到整复,骨折平均愈合时间为44d,术后6周时腕关节活动度达到正常的80％以上.术后并发腕管综合征1例,无肌腱炎及肌腱断裂,无创伤性关节炎.最终疗效根据Dienst腕关节功能评估标准进行评定:优22例,良2例,可1例.结论 中青年桡骨远端关节内粉碎性骨折常为高能量损伤,多为不稳定骨折,早期切开复位LCP内固定可获得较满意的临床疗效.     

Postoperative morphologic analysis of carpal tunnel syndrome using high-resolution ultrasonography

The authors evaluated the morphologic changes that follow division of the transverse carpal ligament in patients with carpal tunnel syndrome (CTS) using high-resolution ultrasonography. Ten patients, for a total of 20 hands, underwent high-resolution ultrasonographic studies before the operation and 8 months after the operation. They were all diagnosed with bilateral idiopathic CTS. The authors evaluated the configuration of the median nerve and carpal tunnel at 3 different levels of the wrist: the distal radiocarpal joint level, the pisiform level, and the hook of hamate level. The median nerve gained in thickness to a remarkable extent at 2 distal levels after the operation. The change in morphology of the carpal tunnel at these 2 distal levels was obvious, but the cross-sectional area of the carpal tunnel was increased significantly only at the hook of hamate level. The transverse diameters of the carpal tunnel were not significantly changed. As mentioned, the authors found that the median nerve gained significantly in volume at the distal part of the carpal tunnel postoperatively, and the volumetric increase in the carpal tunnel appears to have resulted from an anterior displacement of newly formed transverse carpal ligament, rather than from a widening of the bony carpal arch.     

掌侧锁定钢板治疗桡骨远端不稳定骨折

目的探讨掌侧锁定钢板治疗桡骨远端不稳定骨折的治疗效果。方法对56例桡骨远端不稳定骨折患者采用切开复位掌侧锁定钢板内固定治疗,其中13例复位后骨缺损严重者行人工骨植骨。结果 56例均获随访,时间13~24个月。X线片显示骨折全部愈合。按Gadand-Werley评分标准:优12例,良33例,可10例,差1例。发生腕管综合征4例,拇伸肌腱激惹3例,局部疼痛1例。结论掌侧锁定钢板能有效维持桡骨远端不稳定骨折的复位,但存在各种并发症,处理得当基本能获得满意的腕关节功能。     

Internal neurolysis fails to improve the results of primary carpal tunnel decompression

This prospective, randomized study compares two treatment methods in patients with primary carpal tunnel syndrome. Decompression of the transverse carpal ligament was done in thirty-two hands (thirty patients) and decompression of the transverse carpal ligament with the addition of an internal neurolysis of the median nerve was done in thirty-one hands (twenty-nine patients). Relief of symptoms was described in eighty-eight percent of the patients with carpal ligament release and eighty-one percent of patients with carpal ligament release plus internal neurolysis. Improvement in hand sensibility testing, in thenar muscle strength, and atrophy was noted in both treatment groups with no statistical difference between groups. The addition of an internal neurolysis to division of the transverse carpal ligament does not add significant improvement in the sensory or motor outcome of patients with primary carpal tunnel syndrome.     

Hand numbness and carpal tunnel syndrome after volar plating of distal radius fracture

We report the incidence of late onset post-operative carpal tunnel syndrome (late carpal tunnel syndrome) and late median nerve neuropathy after volar plating of distal radius fracture by conducting a retrospective study on volar plating for distal radius fracture performed during 2002 to 2006. Two hundred eighty-two volar plating were performed for acute distal radius fracture after exclusion. Post-operative hand numbness occurred in 24 patients of which nine had carpal tunnel syndrome. Thus, the incidence of late carpal tunnel syndrome was 3.2% (9/282). Of the eight (8/24, 33%) patients with post-operative hand numbness that failed to respond to conservative treatment, five had carpal tunnel release and three had neurolysis of median nerve at distal forearm. All had clinical improvement except in one patient. The incidence of late carpal tunnel syndrome after volar plating of distal radius in the present series is similar to the prevalence of carpal tunnel syndrome in general population. The incidence is low compared with other series, regardless of treatment method (conservative treatment, volar or dorsal plating). The outcome of post-operative hand numbness is generally favourable.     

Measurement of median nerve blood flow during carpal tunnel release with laser Doppler flowmetry.

Eight consecutive median nerves in eight patients with clinical carpal tunnel syndrome were prospectively examined by non-contact laser Doppler flowmetry before and after undergoing carpal tunnel release. Before performing carpal tunnel release, the difference in the median nerve blood flow between the values at the distal and proximal portions to the transverse carpal ligament was statistically significant (p = 0.021). After carpal tunnel release, the median nerve blood flow both distal and proximal to the transverse carpal ligament increased by 1.5 and 1.3 times, respectively, compared to the flow prior to carpal tunnel release, however, only the difference at the distal portion to the transverse carpal ligament was statistically significant (p = 0.015). In this study, we directly measured the median nerve blood flow using non-contact laser Doppler flowmetry and thus demonstrated a significant difference in the median nerve blood flow between the values at the distal and proximal portions to the transverse carpal ligament before carpal tunnel release and a significant increase in the nerve blood flow only at the distal portion to the transverse carpal ligament after surgery. This technique is thus considered to be an easy and reproducible way to intraoperatively evaluate the nerve blood flow in real time during the release of entrapment neuropathies.     

Open reduction and internal fixation of the distal radius

Fractures of the distal radius are one of the most common problems treated by orthopaedic surgeons. The managementof unstable fractures is now almost routinely surgical, and multiple techniques have been developed to accomplish this including pins and plaster, external fixation, and internal fixation. Recent studies and classification systems have stressed the importance of identification of specific fracture fragments. Given that the goal of operative management of the fracture is an anatomic reduction and stable fixation, open reduction and internal fixation has been utilized recently to a greater degree. This allows direct reduction of the fracture with a stable construct. Advantages over external fixation or pins and plaster include a more anatomic reduction, establishment of early range of motion, and avoidance of complications associated with external pins. A dorsal or volar approach can be employed depending on fracture pattern and associated bony or soft tissue injuries. A variety of plating systems are now available, many of which are contoured specifically for the distal radius. Results of open reduction and internal fixation for distal radius fractures have generally shown greater than 80% good results. Complications can also occur including tenosynovitis, tendon rupture, and carpal tunnel syndrome.