桡骨远端骨折与腕关节不稳的临床研究

目的研究桡骨远端骨折保守和手术治疗后腕关节不稳的转归及关节不稳对功能的影响。方法1999年1月～2004年3月,临床随访124例采用石膏、外固定支架和桡骨远端钢板固定治疗的桡骨远端骨折患者,根据X线片测量判断治疗前、后腕关节不稳的变化,Gartland与Werley评分标准评定腕关节功能恢复情况。结果随访中发现有背侧偏移、掌侧偏移、背屈不稳(DISI)、掌屈不稳(VISI)和舟月分离五种腕关节不稳;治疗前、后和随访时腕关节不稳发生率分别为58.1%、21.8%和22.6%;优良率为80.6%,稳定组和不稳定组优良率分别为84.5%和75.0%。结论桡骨远端骨折后常可合并不同类型的腕关节不稳,手术治疗可以有效纠正桡腕关节不稳,舟月分离性腕关节不稳很难被纠正,腕关节不稳定组的腕关节功能明显比腕关节稳定组差,桡腕关节的完整性是影响腕关节功能的主要因素。     

Fernandez Ⅳ型桡骨远端骨折脱位的微创治疗

目的：探讨采用小切口微创复位腕关节动力外固定支架结合克氏针治疗FernandezⅣ型桡骨远端骨折脱位的临床疗效.方法：自2007年1月至2012年10月,选取桡骨远端骨折（FernandezⅣ型,韧带附着点撕脱型骨折）合并桡腕关节脱位患者19例,男14例,女5例;年龄22～42岁,平均36.5岁.采用微创复位,安装动力外固定支架,克氏针维持固定桡腕关节面及纠正背伸不稳、掌屈不稳.测定腕关节的活动范围和影像学指标,对腕关节功能进行Gartland-Werley评分评定腕关节功能恢复情况.结果：术后无钉道感染、固定松动和医源性神经血管损伤.行标准腕关节正侧位X线摄片,测量得桡月角（9.5±3.3）°,舟月角（51.3±11.2）°,桡骨远端长度（11.2±1.8）mm.随访未出现再移位,无桡腕关节的半脱位或背伸不稳、掌屈不稳.术后3个月Gartland-Werley功能评分3.02±3.05.结论：FernandezⅣ型桡骨远端骨折脱位采用小切口微创复位腕关节动力外固定支架结合克氏针有限内固定的治疗方案疗效确切,可恢复正常桡月角、舟月角及桡骨远端长度.     

桡骨远端骨折伴腕关节不稳的临床分析

目的分析合并腕关节不稳的桡骨远端骨折不同治疗的功能影响。方法临床随访72例合并腕关节不稳的桡骨远端骨折,通过传统的手法复位石膏固定及手术治疗,根据X线片测量判断治疗前后腕关节的变化,按Frykman分型、汤锦波提出的腕关节不稳定的分型标准及Gartland和Werley评分评定腕关节功能恢复情况作分析。结果随访中发现有背侧偏移、掌侧偏移、背屈不稳(DISI)、掌屈不稳(VISI)和舟月分离5种腕关节不稳;腕关节不稳纠正率为75%;手术组为90.9%;非手术组为46.7%;手术组功能优良率为85.2%,非手术组为72.2%。结论桡骨远端骨折后常可合并不同类型的腕关节不稳定,手术治疗能提高腕关节不稳的纠正率,提高临床疗效。     

手法复位小夹板分期治疗桡骨远端关节面背侧缘粉碎性骨折伴桡腕关节脱位

目的探讨采用手法复位小夹板分期治疗桡骨远端关节面背侧缘粉碎性骨折伴桡腕关节半脱位或全脱位的临床疗效。方法对桡骨远端关节面背侧缘粉碎性骨折伴桡腕关节脱位26例进行手法复位小夹板外固定分期治疗。结果所有患者获得随访10-38个月,20例骨折愈合且无明显的对线不良,6例出现骨折移位或桡腕关节半脱位,其中4例进行手术修复,2例拒绝手术治疗,采用非手术治疗。腕关节和前臂最后平均活动度为：掌屈62°,背伸54°,桡偏27°,尺偏25°,旋前85°,旋后75°。最后评估时所有患者的每个指尖均可顺利地触及远侧掌横纹。平均为健侧握力的80%。根据Gartland和Werley评分：优14例,良9例,可3例。结论利用韧带整复原理非手术治疗桡骨远端关节面背侧缘粉碎性骨折伴桡腕关节半脱位或全脱位可使大多数患者恢复满意的疗效,但围治疗期处理同样非常重要。     

桡骨远端关节内骨折对腕关节影响的生物力学研究

目的研究桡骨远端关节内骨折对桡腕关节的影响。方法12只成人上肢标本于距关节面3cm处截骨去除1cm骨块,于桡骨远端关节面舟骨窝与月骨窝交界处纵形劈开桡骨,使桡尺侧骨块可分别向近端移动,制作桡骨远端关节内骨折模型,利用压敏片测试随关节面移位,桡腕关节面的应力分布和受力面积改变情况。结果桡舟关节面移位≥2mm时,月骨接触面积及接触应力增加,舟骨接触面积及接触应力减少(P<0.01);桡月关节面移位≥2mm时,舟骨接触面积及接触应力增加(P<0.01),月骨接触面积无明显变化(P>0.01)而及接触应力减少(P<0.01)。结论桡骨远端关节内骨折关节面移位≥2mm以上时,桡腕关节面的应力分布和受力面积发生改变,影响腕关节功能。     

掌背侧联合入路分步复位内固定治疗AO-C3型桡骨远端骨折

目的 探讨掌背侧联合入路并掌背侧分步复位内固定治疗AO-C3型桡骨远端骨折的临床疗效与手术方法。方法回顾性分析自2016-02—2021-03采用掌背侧联合入路并掌背侧分步复位内固定治疗的17例单发AO-C3型桡骨远端骨折,所有病例均先行掌侧Henry入路,显露桡骨远端掌侧关节面骨折块后,复位掌侧骨折块并先行锁定板单皮质锁定钉内固定,然后取背侧切口显露背侧、桡骨茎突骨折块和关节面塌陷骨折块,以掌侧骨块复位后的关节面为参照来复位骨折块并固定。比较双侧掌倾角、尺偏角、桡骨高度、腕关节屈伸范围、尺桡偏、前臂旋转活动度、握力,采用DASH评分和与Mayo腕关节功能评分评价腕关节功能。结果 所有患者均获得随访,随访时间12～27个月,平均15.3个月。所有骨折均愈合,无感染和血管神经损伤发生。术后3、6、12周患侧的掌倾角、尺偏角、桡骨高度与健侧比较,差异无统计学意义（P>0.05）。末次随访时患侧的腕关节屈伸范围、尺桡偏、前臂旋转活动度、握力与健侧比较,差异无统计学意义（P>0.05）。末次随访时患侧DASH评分平均36.9(32～42)分,Mayo腕关节功能评分平均89.5(81...     

关节镜辅助治疗桡骨远端关节内骨折

目的 报告关节镜在桡骨远端关节内骨折复位固定中的辅助作用.方法 回顾2004-2007年间我院收治的12例桡骨远端骨折,在开放复位内固定术中应用关节镜进行腕关节内观察,检测关节面的对位情况,术后以放射学检查评估关节面的对位,并测量桡骨高度、掌倾角及桡偏角,随访临床腕关节功能恢复情况.结果 随访时间平均为24个月,12例桡骨远端关节内骨折术后均未出现关节面阶梯改变.X线片检查:桡骨高度平均为12 mm(7～15 mm),掌倾角平均为5°(1°～9°),桡偏角平均为20°(14°～28°).腕关节活动度:屈曲平均为33°(18°～42°),背伸平均为38°(21°～42°).6例活动时有轻微疼痛.根据Gartland和Werley的评估标准评定:优5例,良7例.结论 应用腕关节镜辅助治疗桡骨远端关节面骨折复位可避免关节面出现阶梯改变,最大程度地恢复关节的功能.     

两种入路桡骨茎突骨瓣植入治疗陈旧性舟状骨骨折疗效分析

目的观察桡背侧和桡掌侧入路植入桡骨茎突骨瓣治疗陈旧性舟状骨骨折的疗效。方法选取2011年3月-2012年12月采用桡背侧和桡掌侧入路植入桡骨茎突骨瓣治疗陈旧性舟状骨骨折患者22例,对其进行回顾性分析．观察术后1个月、2个月、3个月、6个月的X线片,确定骨折愈合情况;观察术后6个月、1年时腕关节功能恢复情况。结果本组患者术后6个月时舟状骨骨折全部愈合,腕关节活动度良好。结论桡背侧和桡掌侧入路植入桡骨茎突骨瓣治疗舟状骨陈旧性骨折的手术时间短,疗效明确,术后腕关节功能恢复良好。     

桡骨远端不稳定型骨折的微创治疗

目的评估桡骨远端不稳定型骨折微创治疗的手术疗效。方法对64例桡骨远端不稳定型骨折患者进行回顾性研究,在手术后1～3年,测定腕关节的活动范围和影像学指标,对腕关节功能进行Gartland-Werley评分。结果患侧腕关节的背伸和尺偏活动范围显著小于正常腕关节（P〈0.05）,掌曲、桡偏、旋前和旋后活动范围与正常腕关节无显著性差异（P〉0.05）。掌倾角显著小于正常腕关节（P〈0.01）,桡骨高度和尺偏角无显著性差异（P〉0.05）。Gartland-Werley功能评分优良率为90.6%。结论闭合复位,外固定支架结合经皮克氏针固定能有效治疗桡骨远端不稳定型骨折。     

掌侧锁定加压接骨板治疗桡骨远端不稳定性骨折

目的评价切开复位锁定加压接骨板（LCP）内固定治疗桡骨远端不稳定性骨折的效果。方法对21例桡骨远端不稳定性骨折采用掌侧入路切开复位LCP内固定治疗。其中5例做了植骨。结果21例均获随访,时间6～19（13．0±3．9）个月,患者骨折均愈合。桡骨远端的掌倾角平均9．6°±3．7°;尺偏角平均21．4°±2,3°;桡骨短缩≥2mm2例,其余皆〈2mm;关节面移位均〈1mm。用改良的Gartland和Werley评分系统评估腕关节功能：优14例,良5例,中1例,差1例。结论切开复位掌侧LCP内固定是治疗桡骨远端不稳定性骨折的有效方法,辅以植骨能有效防止关节面塌陷和促讲骨折愈合。     

桡骨远端骨折类型和腕不稳定关系

目的 研究桡骨远端骨折类型对腕不稳定发生的作用。方法 在160例正常腕关节测量并确定腕不稳定标准基础上,比较236例桡骨远端骨折中桡骨远端关节面不平整(52例)、桡骨明显缩短(50例)、桡骨远端关节面背倾(43例)和伴尺骨茎突骨折(65例)与无以上因素的一般骨折(63例)不稳定发生率及类型,分析以上骨折相关因素的严重程度和不稳定发生的关系。结果 伴有尺骨茎突骨折例腕不稳定发生率为47.7％,腕关节背倾例中发生率为30.2％,桡骨明显缩短例中发生率为22％,关节面不平整例中发生率为17.3％,一般骨折例中发生率为7.8％。腕不稳定例的桡骨缩短、关节面背倾和尺骨茎突骨折移位程度与无不稳定的比较有显著差异。结论 桡骨远端骨折的关节面不完整、桡骨明显缩短、关节面背倾和伴尺骨茎突骨折对腕不稳定例发生及程度有显著影响。     

Bone malalignment in acute injuries of the wrist.

The purpose of this study was to analyze radiographic signs of carpal bone instability in patients with an acutely injured wrist. There were 80 patients (52 women and 28 men) with a fall on the outstretched hand. Fifty patients had a fracture of the distal radius, and eight had a scaphoid fracture. The patients with a bone fracture showed a larger scapholunate angle than those without a fracture (P less than 0.001, t-test). However, only four of them showed true carpal bone instability: two patients with a scaphoid fracture and one with a radius fracture had dorsiflexion instability of the wrist and one patient with a radius fracture had dorsal subluxation of the wrist. In addition, one patient without any bone fracture had scapholunate dissociation, one form of carpal bone instability. Although carpal bone instability is not frequent in an acutely injured wrist, its signs should be remembered in the radiographic analysis of the traumatic wrist to prevent subsequent articular disorders.     

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。     

A biomechanical study of distal radial fractures

In an attempt to explain disability in dorsally angulated malunited distal radius fractures, an experiment was designed to evaluate load patterns about the wrist with varying degrees of dorsal angulation of the distal radius. Osteotomies were made in the distal radius of fresh cadaver arms after a modified external fixator was applied to the radius and load cells applied to the proximal radius and ulna. Pressure-sensitive film was inserted into the radioulnar carpal joint. After a predetermined load was applied to the wrist it was found that the load through the ulna increased from 21% to 67% of the total load as the angulation of the distal radial fragment increased from 10 degrees of palmar tilt to 45 degrees of dorsal tilt. The pressure distribution on the ulnar and radial articular surfaces changed in position and became more concentrated as dorsal angulation increased.     

Open Wedge Osteotomy for Malunited Extraarticular Distal Radius Fractures with Plate Osteosynthesis without Bone Grafting

Abstract Background: Malunion of distal radius fractures can cause pain, limited wrist motion, or loss of grip strength. The most important factors are incongruity in the distal radioulnar (DRU) joint and radial tilt which causes adaptive carpal instability. The purpose of open wedge corrective osteotomy is to restore congruency with minimal soft-tissue damage. Patients and Methods: Between 1993 and 2001, 47 patients with malunited extraarticular distal radius fractures who were treated by open wedge corrective osteotomy without bone grafting were included. The patients were divided into two groups, one group with dorsal tilt of the distal radius and one group with palmar tilt. Ulnar variance, radial inclination, and radial tilt were measured before and after operation. Also, the range of wrist motions was tested before and after correction, including grip strength. Fixation was performed with a dorsal or palmar plate, dependent on the side of radial tilt. Results: Improvement of especially radial tilt was seen in both groups. Also, an important increase in wrist motions was observed. Flexion of the wrist improved by 38.0° in the dorsal group and by 43.0° in the palmar group. With respect to rotation of the lower arm, supination improved most by 21.6° and 46.0° in the dorsal and palmar group, respectively. All osteotomies healed within 3 months without secondary displacement even after a short period of immobilization. Conclusion: Corrective osteotomy is a useful additional therapy in the treatment of malunited extraarticular fractures of the distal radius in which bone grafting is not necessary.     

Ulnar bursa distention following volar subluxation of the distal radioulnar joint after distal radial fracture: a rare cause of carpal tunnel syndrome

This report describes an eighty-four-year-old woman with persistent carpal tunnel syndrome attributable to an ulnar bursa distention associated with the subluxation of the distal radioulnar joint after distal radial fracture. During surgery, when the forearm was placed in supination, the ulna head with a sharp osteophyte was found to be displaced into the carpal tunnel through a defect of the ruptured capsule of the wrist joint. This volar subluxation of the ulnar head had caused distention of the ulnar bursa, causing compression of the median nerve, which resulted in carpal tunnel syndrome. In addition to reduce displaced fractured segment to obtain anatomic articular surface, original radial length and tilt, the anatomic restoration of the distal radioulnar joint is essential to maintain better long-term function after fracture of the distal radius.     

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。