Colles骨折合并舟骨月骨分离

目的 探讨Colles骨折合并舟月骨分离的治疗方法。方法 对40例Colles骨折合并舟月骨分离的患者,采用适当地延长对抗牵引时间和闭合手法复位,整复后以中立位、轻度背伸位固定治疗。结果 经6-18个月的随访。40例患者全部获得骨性愈合,根据腕关节运动功能综合评定,优23例,良12例,可5例,优良率达86.9%。结论 舟月骨分离是腕不稳定的主要因素。治疗首先要力争使骨折复位,纠正腕关节的动力性不稳定,同时要恢复舟月骨间的正常解剖关系。传统的掌屈尺偏位固定。石油利于改善腕关节不稳定状态。     

Colles骨折与舟月骨分离

作者对３８例Ｃｏｌｌｅｓ骨折登工舟月骨分离患者，采用适当延长对抗牵引时间，闭合手法得位，整复后中立位或轻度背伸位固定的治疗，经６－１８个月的随访，优良率８６．８４％。认为舟月分离是腕不稳定的主要因素之一。治疗首先要力急使骨折解剖复位，以纠正腕关节的动力性不稳定。     

腕舟骨骨折和经舟骨月骨周围脱位

舟骨骨折可区分为稳定骨折和不稳定骨折两类。舟骨不稳定骨折系指舟骨骨折伴有舟月两骨不稳定,由舟骨骨折移位或经舟骨月骨周围脱位造成。舟骨骨折移位系指移位超过1mm。舟骨骨折和经舟骨月骨周围脱位的治疗原则是早期诊断、解剖复位和足够固定。不稳定骨折需用克服舟月两骨不稳定的措施,以防止发生骨折不愈合。 1 舟月两骨不稳定的X线片检查法 1.1 X线侧位片的正常特征 正常腕关节中和位时,舟骨呈倾斜位,其掌侧面略呈凹陷状;桡骨和头状骨位于同一纵轴线;月骨前后两缘的连线与桡骨纵轴线呈垂直位,其延长线位于舟骨结节上方(图1,左)。 1.2 月骨前后两缘连线的延长线检查法 舟月骨不稳定时,舟骨趋向水平位,月骨前后两缘连线的延长线位于舟骨结节部(图1,有)     

Colles骨折与腕关节不稳定

目的探讨Colles骨折合并腕关节不稳定的发生机制和防治措施。方法对53例Colles骨折随访3～5年,测量其复位前、后和去除外固定后的腕关节正、侧位平片,并测定腕关节功能的主、客观指标。比较合并与不合并腕关节不稳定两组的功能恢复情况。结果伴有腕关节不稳定的发生率为41.5%(22/53),其中腕背不稳定（DISI）10例（45.5%）,舟月分离12例（54.5%）,多发生在严重骨折移位,高能量损伤的患者。骨折愈合后,合并腕关节不稳定的功能明显差于单纯Colles骨折患者。结论对骨折移位严重或高能量损伤的Colles骨折,要注意是否合并腕关节不稳定。对合并腕关节不稳定的Colles骨折,复位时应尽可能恢复掌倾角,如骨折稳定,腕关节固定在中立位或轻度背伸位（＜10°）为宜;如骨折不稳定,应固定在掌屈尺偏位,2周后改为固定于中立位或轻度背伸位（＜10°）,以防止远期出现腕关节不稳定。     

腕关节镜联合机器人导航技术在经舟骨月骨周围背侧脱位治疗中的应用

目的探讨腕关节镜辅助下复位经舟骨月骨周围背侧脱位, 机器人导航经皮内固定舟骨的临床疗效。方法我科自2019年11月至2021年11月对7例经舟骨月骨周围背侧脱位患者, 采用腕关节镜辅助复位, 机器人导航下经皮空心加压螺钉内固定舟骨, 克氏针经皮内固定月骨三角骨。术后功能位支具固定, 定期摄X线片和腕关节CT观察骨折愈合情况。结果 7例患者均获得随访, 时间为8～20个月, 平均13.5个月。7例患者舟骨均获得愈合, 亦无月骨坏死及舟月、月三角分离发生。采用改良Mayo腕关节评分标准评定:优6例, 良1例。结论腕关节镜联合机器人导航治疗经舟骨月骨周围背侧脱位, 复位精准, 螺钉位置满意, 疗效可靠, 是一个值得推荐的治疗方法。     

闭合复位经皮空心螺钉固定治疗Herbert B1、B2型腕舟状骨骨折

目的探讨闭合复位经皮空心螺钉固定治疗轻微移位腕舟状骨骨折的临床疗效。方法对15例Herbert B1、B2型腕舟状骨骨折患者采用闭合复位经皮空心螺钉固定治疗。术后定期摄腕关节X线片评价骨折愈合情况,采用改良Mayo腕关节功能评分及疼痛VAS评分评价功能情况。结果 15例均获得随访,时间6~24个月。患者骨折愈合时间6~12周,未出现骨不愈合及骨坏死。末次随访时,Mayo评分80~100分,其中优11例,良4例;VAS评分为0~3分。结论闭合复位经皮空心螺钉固定创伤小,能最大程度保护舟状骨周围血供,有效避免了舟状骨坏死的发生,且固定牢靠,允许早期功能锻炼,术后功能恢复优良,是治疗Herbert B1、B2型腕舟状骨骨折的有效方法。     

微型哈勃螺钉内固定治疗腕舟状骨骨折疗效分析

目的 总结腕舟状骨骨折采用微型哈勃螺钉内固定手术治疗结果并加以分析.方法 对腕舟状骨骨折10例采用腕桡侧切口切开复位、微型哈勃螺钉内固定.评价骨折愈合情况和腕关节功能.结果 骨折全部愈合,骨折愈合时间2.2～3.9个月,平均3.0个月.腕关节功能得到明显改善.结论 腕舟状骨骨折采用微型哈勃螺钉内固定手术治疗,易于骨折愈合、疗效确切.     

可吸收螺钉治疗不稳定型腕舟状骨骨折17例疗效分析

目的探讨可吸收螺钉治疗不稳定型腕舟状骨骨折的临床疗效。方法回顾性分析17例不稳定型腕舟状骨骨折患者的临床资料,骨折端均有移位但无明显骨质缺损,均采用切开复位、可吸收螺钉内固定治疗。结果17例均获随访,平均10(8~12)月,均获骨性愈合,骨性愈合时间平均6.4月,腕关节活动范围在106°~128°之间。疗效评价:优11例,良5例,差1例。结论可吸收螺钉内固定对腕舟状骨骨折的加压固定可靠,可避免二次手术取出内固定,对腕关节损伤小,是治疗不稳定腕舟状骨骨折的有效方法。     

掌侧入路手术治疗急性月骨周围骨折-脱位

目的评价掌侧入路手术治疗急性月骨周围骨折-脱位的方法及疗效。方法对2010-2017年收治的11例急性月骨周围骨折-脱位患者采用掌侧入路,术中复位月骨周围脱位,固定合并的骨折,修复掌侧关节囊韧带,术中判断月骨周围关节稳定则不再行关节内固定术,术后石膏托制动4周。末次随访采用Mayo腕关节评分评定疗效。结果术中修复掌侧关节囊韧带及固定合并的骨折后,10例月骨周围关节稳定,1例仍存在舟月关节分离,加用克氏针固定。11例均获得随访,随访时间9~17个月,末次随访,所有患者均重返原工作岗位。患侧腕关节平均屈伸活动度为106.2°,平均握力相当于健侧的87%。采用Mayo腕关节评分评价腕关节功能:优6例,良4例,可1例。结论采用掌侧入路切开复位、修复掌侧关节囊韧带、不常规使用关节内固定的方法治疗急性月骨周围骨折-脱位疗效满意。     

经舟骨月骨周围脱位的治疗

目的 探讨经舟骨月骨周围脱位的治疗方法。方法 采用经皮撬拨复位月骨,舟状骨切开复位,自体桡骨茎突植骨,克氏针内固定治疗经舟骨月骨周围脱位11例,随访6-18个月,平均10个月。结果 3个月内骨折愈合,腕关节不痛,活动正常,恢复伤前所有功能7例;半年内骨折愈合,活动正常,腕关节剧烈活动后疼痛2例;1例后骨折愈合,腕关节活动度差1/3以下,腕关节存在运动性疼痛1例;骨折未愈合,或舟状骨、月骨一处坏死,腕关节疼痛,功能严重丧失1例,优良率81.82%。结论 采用经皮撬拨复位月骨,舟状骨切开复位,自体桡骨茎突植骨,克氏针内固定治疗经舟骨月骨周围脱位,具有损伤小、痛苦少、易操作、费用低、功能恢复满意的优点。     

创伤性舟月骨分离的腕动力学研究

目的 通过生物力学研究,探讨腕创伤性舟月骨分离及临床并发症的生物力学机制和治疗要求。方法 采用７只新鲜冷冻尸体上肢,分别在腕关节完整、舟月骨间韧带切断、中度及重度舟月骨间隙增大四个实验测定腕关节屈伸和尺桡偏运动时,腕主要运动肌腱的滑动距离,并根据滑动距离和关节运动角度与力臂之间的关系计算机肌腱力臂。结果 在舟月骨间韧带切断后腕屈伸运动时桡侧伸腕肌腱的力臂明显增大;在舟月骨间韧带切断及舟月骨间隙增大     

Kinematics of the midcarpal and radiocarpal joint in flexion and extension: an in vitro study

PURPOSE: To apply carpal kinematic analysis using noninvasive medical imaging to investigate the midcarpal and radiocarpal contributions to wrist flexion and extension in a quasidynamic in vitro model. METHODS: Eight fresh-frozen cadaver wrists were scanned with computed tomography in neutral, full flexion, and full extension. Body-mass-based local coordinate systems were used to track motion of the capitate, lunate, and scaphoid with the radius as a fixed reference. Helical axis motion parameters and Euler angles were calculated for flexion and extension. RESULTS: Minimal out-of-plane carpal motion was noted with the exception of small amounts of ulnar deviation and supination in flexion. Overall wrist flexion was 68 degrees +/- 12 degrees and extension was 50 degrees +/- 12 degrees. In flexion, 75% of wrist motion occurred at the radioscaphoid joint, and 50% occurred at the radiolunate joint. In extension, 92% of wrist motion occurred at the radioscaphoid joint, and 52% occurred at the radiolunate joint. Midcarpal flexion/extension between the capitate and scaphoid was 0 degrees +/- 5 degrees in extension and 10 degrees +/- 13 degrees in flexion. Midcarpal flexion/extension between the capitate and lunate was larger, with 15 degrees +/- 11 degrees in extension and 22 degrees +/- 19 degrees in flexion. CONCLUSIONS: The capitate and scaphoid tend to move together. This results in greater flexion/extension for the scaphoid than the lunate at the radiocarpal joint. The lunate has greater midcarpal motion between it and the capitate than the scaphoid does with the capitate. The engagement between the scaphoid and capitate is particularly evident during wrist extension. Out-of-plane motion was primarily ulnar deviation at the radiocarpal joint during flexion. These results are clinically useful in understanding the consequences of isolated fusions in the treatment of wrist instability.     

The sagittal band: anatomic and biomechanical study

Forty-eight digits from 12 human adult fresh-frozen and formalin-preserved cadaveric hands were used to study the anatomy and biomechanics of the sagittal band (SB) and to investigate the mechanism of its injury. The SB was observed to be part of a complex retinacular system in proximity to the metacarpophalangeal (MCP) joint collateral ligaments and the palmar plate. Dynamic changes in SB fiber orientation were observed with different positions of the MCP and wrist joints. The fibers were perpendicular (0 degrees ) to the extensor tendon in neutral position, distally angulated 25 degrees at 45 degrees of MCP flexion, and 55 degrees with full flexion. Swan-Ganz catheter measurements were obtained deep to the SB in varying positions of the MCP joint. The average pressure generation was greatest (50 mm Hg) during full MCP joint flexion and least (30 mm Hg) during 45 degrees flexion. When MCP joint radial or ulnar deviation was added the average measurement was greatest (57) in neutral MCP position and least (35 mm Hg) in 45 degrees flexion. Serial sectioning of the ulnar SB produced no extensor tendon instability. Partial proximal but not distal sectioning of the radial SB produced tendon subluxation. Complete sectioning of the radial SB produced tendon dislocation. Wrist flexion increased tendon instability after radial SB sectioning. We conclude that (1) extensor tendon instability following SB disruption is most common in the long finger and least common in the small finger; (2) ulnar instability of the extensor tendon is due to partial or complete radial SB disruption, (3) the degree of extensor tendon instability is determined by the extent of SB disruption, (4) proximal rather than distal SB compromise contributes to extensor tendon instability, (5) great forces are inflicted on the SB while the MCP joint is in full extension or less frequently in full flexion, which may be the mechanism of its injury, and (6) wrist flexion contributes to extensor tendon instability after SB disruption and may exacerbate the severity of its injury.     

桡骨远端骨折对腕关节稳定性的影响

目的研究各型桡骨远端骨折导致的腕关节不稳手术与非手术治疗的临床疗效及对腕关节稳定性的影响。方法1999年1月至2006年9月桡骨远端骨折患者200例,采用AO分型,标准腕关节正侧位片测量桡月角、舟月角、桡骨远端长度、关节面落差、舟月近远侧间距。手法复位石膏外固定患者和桡骨远端切开复位内固定治疗患者进行比较,采用改良Gartland和Werley评分标准评定腕关节功能恢复情况,并进行统计学分析。结果临床平均随访时间5年2个月,结果发现舟月分离、背屈不稳、掌屈不稳、背侧偏移和掌侧偏移5种腕关节不稳;优良率为78％。桡骨远端长度缩短≥2．5mm与〈2．5mm的桡骨远端骨折患者腕关节不稳发生率比较,Fisher确切概率P〈0．01;桡骨远端关节面的落差≥2mm与〈2mm的桡骨远端骨折患者腕关节不稳发生率比较,Fisher确切概率P〈0．01。结论桡骨远端骨折对桡腕关节面、桡骨远端长度、掌倾角的恢复与患者的疗效密切相关,腕关节的稳定性依赖于骨性结构和周围韧带的完整性,腕关节不稳将严重影响腕关节功能。对于严重关节内的骨折应手术治疗解剖复位。     

创伤性腕关节不稳定手术治疗

目的 报道创伤性腕不稳定的手术方法。方法 16例腕不稳定中,表现为舟月骨分离6例,以腕背侧镶嵌不稳定(DISI)为主10例。对于舟月骨分离及DISI采用舟月骨间韧带重建手术6例,舟月头骨固定手术3例;对于DISI采用背侧关节囊固定术3例,桡骨远端截骨矫正术4例。结果 术后观察1至2年患者疼痛明显缓解,手握力提高,日常生活满意度改善,功能较术前恢复。结论积极采取手术治疗腕不稳定,重建损伤韧带或纠正畸形,是治疗腕关节不稳定有效的方法。     

Early results of reconstruction of the dorsal scapholunate ligament

We present the clinical results of a study of chronic dynamic scapholunate (SL) dissociation treated by reconstruction of the dorsal SL ligament. A total of 35 patients who presented with chronic dynamic SL instability had the scapholunate ligament reconstructed with a tendon graft. Twenty-nine patients were available for follow-up evaluation after a minimal interval of 17 months (range 17-72). Patients' satisfaction was good in 26/29 patients. Postoperative range of movement was reduced in extension and improved for flexion and ulnar deviation. Mean wrist movements were 75% of those on the opposite side. Most patients had good pain relief and recovered their grip strength, and returned to their regular employment. Follow-up stress radiographs showed a reduction in the SL angle and gap. Reconstruction of the dorsal SL ligament provides sufficient restoration of stability, pain relief, and functional improvement of the wrist for patients with dynamic SL instability. Although the short-term results are encouraging, we think that this method should be verified by longer follow-up.     

Lunate-triquetral and midcarpal joint instability.

Instability of the ulnar side of carpus centers around the triquetrum, which is suspended by the ulnar triquetral ligaments and supported proximally by the TFCC. The triquetrum guides the lunate by an interosseous membrane and stout palmar ligaments that provide a relatively rigid connection between the two bones. Disruption of the LT ligament is frequently associated with pathology in the ulnar carpal area and may progress to triquetral instability, VISI, and finally, degenerative arthritic changes on the ulnar side of the carpus. The diagnosis of LT injuries is made by stress radiographs, arthrography, video-fluoroscopy, and arthroscopy. Treatment is initially nonoperative, but if symptoms persist, surgery is warranted. Arthroscopic debridement and pinning the LT joint, ligament repair or reconstruction, and intercarpal arthrodesis have all been reported as successful treatments. For the chronic problem confined to the LT joint, a limited intercarpal arthrodesis of the joint is the most predictable procedure for relieving pain without causing any significant restrictions in wrist motions. When there is a dissociation pattern in addition to LT instability, a more extensive intercarpal arthrodesis is required. Midcarpal instability occurs at the triquetral-hamate joint and is characterized by a dynamic subluxation of the joint. During ulnar deviation, the joint undergoes an exaggerated shift from volar flexion to dorsiflexion. Supportive care is generally successful; although in chronic cases, a midcarpal joint arthrodesis is often required.     

Wrist flexion strength after excision of the pisiform bone

Diseases of the pisiform triquetral (P-T) joint and the pisiform itself are often treated with excision of the pisiform bone. The flexor carpi ulnaris (FCU) tendon inserts on the volar aspect of the pisiform, suggesting a loss of strength in wrist flexion following excision of the bone. Isometric and dynamic, isokinetical measurements were made using a strain-gauge dynamometer (Cybex II). Slight postoperative reduction of wrist flexion strength, compared with the contralateral wrist, was noted but not of clinical significance. It is concluded that one should not refrain from excision of the pisiform bone for fear of considerable strength loss in wrist joint flexion.     

Scapho-trapezio-trapezoidal arthrodesis for scapho-trapezio-trapezoidal osteoarthritis

Scapho-trapezio-trapezoid arthrodesis was originally performed for the treatment of scapho-lunate instability. However, only a few publications have described this technique for treatment of osteoarthritis of the scapho-trapezio-trapezoid (STT) joint. The purpose of this paper is to analyze the results of triscaphoid arthrodesis for STT osteoarthritis with a long-term follow-up. Thirteen cases of osteoarthritis of the STT joint in twelve patients, all treated by STT arthrodesis, were reviewed with an average follow-up of 60 months. Pain was classified according to Alnot's classification: eight patients were classified as grade III, two as grade IV and two as grade II. The average preoperative range of motion of the wrist was 51 degrees for flexion, 39 degrees for extension, 9 degrees for radial deviation and 28 degrees for ulnar deviation. Grip strength was compared to the contralateral side. Radiographic changes were classified according to Crosby's classification, including sublevels for carpal instability. Four wrists were classified 2a and nine wrists were classified 2b. The average radio-lunate and scapho-lunate angles were 14 and 45 degrees respectively. Pain was improved in all patients (P = 0.05) all of whom were subjectively satisfied. Strength and range-of-motion did not statistically decrease after STT arthrodesis except for wrist extension (P = 0.03). Radio-lunate and scapho-lunate angles were unchanged in five patients and improved in five patients. There were four non-unions of whom two patients without pain were not re-operated. The other two were re-operated with the same technique leading to fusion. Scapho-trapezio-trapezoid arthrodesis is an efficient procedure for STT osteoarthritis with regard to pain reduction. Strength and global range-of-motion are not modified by this procedure. Moreover, as it limits carpal instability, this procedure is preferable in active patients.