创伤性三角纤维软骨损伤急性期的MRI诊断

目的利用ＭＲＩ技术，探讨创伤性三角软骨（ＴＦＣ）损伤急性期的特征，为早期治疗提供依据。方法选择２３例急诊经Ｘ线片确诊为桡骨远端骨折者进行磁共振成像（ＭＲＩ）检查。Ｔ１和Ｔ２Ｗ１应用ＳＥ序列，对ＴＦＣ的信号密度进行评价。结果２３例桡骨远端骨折均同时存在腕部软组织损伤和ＴＦＣ损伤。ＴＦＣ两处损伤是急性期的典型改变。急性期ＴＦＣ损伤可涉及五个部分即中心、尺侧、桡侧、尺桡侧和整体损伤。结论桡骨远端骨折的同时也存在腕部ＴＦＣ的损伤。     

Assessment of articular displacement of distal radius fractures

Intraarticular step and gap displacements represent the most common indication for surgical treatment of distal radius fractures. Most often, treatment decision making relies only on good-quality plain radiographs taken before and after reduction with measurement accuracy maximized by using the longitudinal axis method. When plain radiographs alone prove insufficient, CT scans or tomograms will significantly improve interobserver and intraobserver reliability of measurements, especially when evaluated using the arc method. Tomography is an effective method for postoperative evaluation of fractures immobilized in splints or casts. The role of MRI in assessing intraarticular distal radius fractures is limited to confirming injuries to carpal ligaments or the triangular fibrocartilage complex. Intraoperatively, we use fluoroscopy to obtain 30 degrees cephalad posteroanterior views and as 22 degrees lateral views to best observe articular surface reduction. Our current operative indications include fractures with radiocarpal or distal radioulnar joint step or gap deformities greater than 1-2 mm, gross distal radioulnar joint instability, or those with extensive metaphyseal comminution rendering them particularly unstable after closed reduction. In general, we tend to lean toward operative fixation in younger, more active patients.     

Intra-focal fixation for treating distal radius fracture: Results of 104 cases

Intra-focal fixation for a displaced distal radius fracture is a surgical option that achieves early functional recovery. We report a retrospective evaluation of the results with various types of distal radius fracture, using various fixation materials in 104 patients (69 women and 35 men; average age, 51.4 years; range, 4–91 years). Fracture types classified according to Frykman were: 14 type I, 15 type II, 6 type III, 16 type IV, 10 type V, 16 type VI, 9 type VII, and 18 type VIII. Fixation materials used were: conventional Kirschner wire in 6 patients, threaded Kirschner wire in 38, arum pins in 38, and conehead wedging screws in 22. The results for patients with Frykman types V–VIII fractures were not as good as those for patients with types I–IV. The arum pin and conehead wedging screw were each superior to either Kirschner wire or threaded Kirschner wire in reducing the fracture and in maintaining fixation. Our evaluation suggested that intra-focal fixation was also suitable for treatment of an intra-articular fracture. In elderly patients, we recommend the arum pin and conehead wedging screw as fixation materials, and suggest short-term postoperative immobilization. Received for publication on May 1, 1998; accepted on July 13, 1998     

Computerized tomographic evaluation of acute distal radial fractures.

To learn whether computerized tomography offered additional useful information over conventional radiographic evaluation of acute distal radial fractures in the younger adult, we scanned 22 consecutive injured wrists. Of the distal radial fractures in 19 wrists, sixteen were defined on plain films as intra-articular. In contrast, computerized tomography demonstrated that all fractures of the distal radius had intra-articular extension. In 3 wrists interpreted as being normal on plain films, despite clinical suspicion of a fracture, fractures were confirmed by computerized tomography. As a result of computerized tomography, injuries were assigned a higher Frykman value in 5 cases, and consideration of alternative patient management became necessary in 5 of the 22 patients.     

腕关节镜辅助下Kapandji技术整复桡骨远端Die-punch塌陷型骨折

目的探讨腕关节镜辅助下Kapandji技术整复桡骨远端Die-punch塌陷型骨折的治疗效果。方法自2012年1月至2018年12月,我们共收治31例桡骨远端Die-punch塌陷型骨折患者,骨折均经CT检查确诊,术中在腕关节镜视下用克氏针撬拨复位桡骨远端塌陷骨折块,达到关节软骨面基本平整,进一步检查腕关节内韧带,特别是舟月韧带、月三角韧带和三角纤维软骨复合体的损伤情况,并修复相应韧带损伤。本组骨折均用克氏针结合外固定支架固定。结果术中发现合并舟月韧带损伤5例、月三角韧带损伤2例、三角纤维软骨复合体损伤10例。术后患者伤口均Ⅰ期愈合,并获得随访,时间为6~24个月,平均11.3个月。骨折愈合时间为6?8周,平均7周。术后X线片测量掌倾角6°~17°,尺偏角15°~23°。腕关节功能按Gartland-Werley标准评定:优22例,良7例,可2例,优良率为93.5%。结论腕关节镜辅助下Kapandji技术整复桡骨远端Die-punch塌陷型骨折可准确复位塌陷的关节面,可减少创伤性骨关节炎并发症,又能明确腕关节内韧带和三角纤维软骨复合体等结构的损伤程度,便于早期处理,以防遗留慢性腕关节痛或不稳定。     

Conehead wedging screw for distal radius fractures in elderly patients

A retrospective study was done of the treatment of 76 distal radius fractures in patients older than 55 years, using intrafocal fixation with a conehead wedging screw or a threaded Kirschner wire. The average age of the 57 women and 19 men was 65.9 years. The fracture types classified according to Frykman were: 10 Type I, four Type II, two Type III, 11 Type IV, eight Type V, 10 Type VI, eight Type VII, and 23 Type VIII. The fixation materials used were a threaded Kirschner wire in 37 patients, and a conehead wedging screw in 39 patients. Followups for the two groups were 28 and 26 months, respectively. The conehead wedging screws were superior to the threaded Kirschner wires in maintaining postoperative reduction in displaced, moderately comminuted intraarticular fractures in elderly patients and had a lower complication rate. Intrafocal fixation using a conehead wedging screw may be indicated for treatment of intraarticular fractures with moderate comminution in elderly patients.     

Galeazzi fracture-dislocation: a new treatment-oriented classification

Forty patients with Galeazzi fracture-dislocations were treated with open reduction and internal fixation of the radial shaft fracture. Intraoperative distal radioulnar joint (DRUJ) instability after anatomic reduction was managed with supplemental wire transfixion of the DRUJ (10 patients) or open reduction and triangular fibrocartilage complex repair (3 patients). Two patterns of fracture-dislocation were identified based on the location of the radial shaft fracture. Twenty-two type I fractures were in the distal third of the radius within 7.5 cm of the midarticular surface of the distal radius; 12 of these cases were associated with intraoperative DRUJ instability. Eighteen type II fractures were in the middle third of the radial shaft more than 7.5 cm from the midarticular surface of the distal radius. Only one of these fractures had intraoperative DRUJ instability after open reduction and internal fixation of the radial shaft fracture. A high index of suspicion, early recognition, and acute treatment of DRUJ instability will avoid chronic problems in this complex injury.     

Diagnosis of occult scaphoid fractures and other wrist injuries

To examine the efficacy of repeated clinical examinations and follow-up radiographs, 121 patients were prospectively and consecutively randomised and clinically followed until a final diagnosis was achieved. All of these patients additionally underwent magnetic resonance imaging (MRI) scans within an average of 3 days after trauma to control the results of this study. MRI detected 112 injuries in 82 patients (67%). Twenty-eight (25%) of these injuries were scaphoid fractures. There were 15 fractures of other carpal bones, 14 avulsion fractures of extrinsic ligaments (AFL), 26 other bone injuries (fractures of distal radius, fractures of radial styloid, ulnar head fracture metacarpal fracture, bone bruises), and 29 soft tissue injuries (triangular fibro-cartilaginous complex injuries, complete or partial ruptures of the scapholunate ligament, ruptures of the radial collateral ligament, hemarthrosis). By means of repeated clinical examinations and plain scaphoid views, experienced observers were able to detect all the occult scaphoid fractures within 38 days, as well as most of the other fractures about the wrist except one fracture of the triquetrum. Soft tissue injuries, however, were diagnosed only in two cases of complete scapholunate ligament tears. It was further obvious that 70% of all scaphoid fractures and 60% of the AFLs were detected in a review of the initial X-rays by experienced surgeons. Only 30% of all scaphoid fractures detected were really occult and all of these were diagnosed correctly. This prospective study demonstrates that clinical and radiological standard procedures are reliable in the diagnosis of occult fractures of the carpus and wrist when performed by experienced observers. MRI scans are indicated for early diagnosis of occult fractures and soft tissue injuries about the wrist.     

Ulnar styloid fracture in children: a retrospective study of 46 cases

Ulnar styloid fractures are frequently ignored in the treatment of wrist fractures in children. Forty-six untreated ulnar styloid fractures (40 tip and six base fractures) associated with radial injuries (45 patients) were retrospectively analysed. At the removal of the cast, we recorded that 80% had a nonunion of the styloid fracture. Thirty-five patients were reviewed at an average of 19 months after treatment. Thirty tip fractures and five base avulsions were found. We recorded 28 patients with a good clinical result despite 21 cases of nonunion, whereas seven patients (all nonunions) had a fair result. All the fair results suffered from intermittent pain during sports and movement, radioulnar joint instability and tears of the triangular fibrocartilage complex. It can be concluded that both distal radius and ulnar styloid fractures should be taken into account in the initial treatment and pain associated with a nonunion of the ulnar styloid in a child may be due to a tear of the triangular fibrocartilage complex.     

桡骨远端骨折合并腕关节韧带损伤的关节镜观察

目的 介绍桡骨远端骨折时,腕关节韧带(舟月骨间韧带、月三角韧带和三角纤维软骨复合体)损伤的关节镜观察.方法 对27例桡骨远端骨折,采用腕关节镜辅助治疗,观察舟月骨间韧带、月三角韧带和三角纤维软骨复合体的损伤情况,通过Gsssler腕部韧带损伤等级分型方法和Palmer方法记录损伤级别.采用卡方检验,分析腕关节韧带损伤程度与骨折类型之间的关系.结果 27例腕关节镜下观察均出现舟月骨间韧带、月三角韧带损伤,损伤为Ⅰ～Ⅱ级;25例有三角纤维软骨复合体损伤,损伤大多为Ⅰa型;腕部韧带损伤的程度与骨折的分型无显著关系.结论 桡骨远端骨折时,腕部韧带损伤率较高,采用腕关节镜辅助治疗有利于准确发现腕部韧带的损伤.

Abstract：

Objective To report te incidence and extent of injuries of the scapholunate interosseous ligament (SLIL), lunotriquetral interosseous ligament (LTIL) and triangular fibrocartilage complex (TFCC)observed under wrist srthroscope during treatment of distal radius fractures.Methods Twenty-seven cases of distal radius fractures were treated with wrist arthroscopic assistance.Distal radius fractures were categorized using AO classification.Injuries of SLIL and LTIL were viewed and graded by Geissler's arthroscopic classification of carpal instability/intercarpal ligament injuries.TFCC lesions were recorded by Palmer's classification.Chi square statistical analysis was used to analyze the relationship between the extent of these ligament injuries and the types of distal radius fractures.Results All 27 cases had SLIL and LTIL injuries of grade Ⅰ to grade Ⅱ.25 cases had type Ⅰa TFCC lesions.There was no significant correlation between ligament injuries and the types of fractures.Conclusion There is a high incidence of ligament injury accompanying distal radius fractures.Wrist arthroscope assisted treatment of distal radius fractures can enhance the accurate detection of these carpal ligament injuries.     

The incidence of distal forearm fractures in Zaragoza (Spain)

We present the results of a retrospective study of the epidemiology of distal forearm fractures in patients over 15 years of age in Zaragoza (Spain) during 1998-1999. We analysed a total of 2506 fractures of the distal forearm. Fractures were classified according to age, sex, Frykman classification and mechanism of injury. Fractures were Frykman type III in 23.5% of cases, Frykman II in 17.9%, Frykman IV in 14.5% and Frykman I in 12.8%. The rest of fractures were distributed homogeneously between the remaining fracture types. The mechanisms of injury was low energy in 78.2% of cases and high in 21.8%. Analysis of the age distribution showed an increase in the incidence of this type of fracture over 50 years of age, with a peak between 60 and 69 years as a result of accidental falls. We found an increased incidence in males below 49 years of age, as a result of traffic accidents, and a predominance of females over 50 years of age due to osteoporosis and an increased number of falls.     

Management of soft-tissue injuries in distal radius fractures

Distal radius fractures account for approximately 15% of all fractures in adults, and are the most common fractures seen in the emergency department. Soft-tissue injuries associated with distal radius fractures may influence strategies for the acute management of the fracture, but also may be a source of persisting pain and/or disability despite fracture healing. This article describes soft-tissue injuries and considerations for treatment associated with distal radius fractures, including injuries to the skin, tendon and muscle, ligaments, the triangular fibrocartilage complex, neurovascular structures, and related conditions such as compartment syndrome and complex regional pain syndrome.     

Intraoperative evaluation of DRUJ instability through dorsal stress radiography in distal radius fractures

IntroductionCertain type of injury of the triangular fibrocartilage complex associated with distal radius fracture can result in distal radioulnar joint instability (DRUJ). Untreated DRUJ instability may lead to poor result in the treatment of acute distal radius fractures. The aim of this study was to evaluate DRUJ instability in distal radius fractures through dorsal stress radiography comparing the affected and unaffected wrists intraoperatively.Materials and methods49 patients with a distal radius fracture who were operatively treated with a volar locking plate were included. Dorsal stress radiography was used to evaluate both affected and unaffected wrists peri-operatively to detect DRUJ instability. Under general anesthesia, a dorsal stress test was performed on the unaffected wrist. Additionally, after fixation of the affected wrist, a dorsal stress test was performed. The ulnar translation ratio (UTR) was measured through the dorsal stress radiograph. Arthroscopic examination was performed on all affected wrists according to Palmer's and Atzei classification.ResultsThe UTR of the affected wrist and the TFCC injury Palmer-type IB tendency were positively correlated (odds ratio: 1.18, p-value: 0.002). Additionally, as the UTR difference between the affected and unaffected wrists enlarged, it revealed a significant DRUJ instability tendency due to Palmer-type IB TFCC injury (p-value: 0.000006, Wilcoxon rank-sum test).ConclusionsDorsal stress radiography is a reliable, simple procedure to evaluate DRUJ instability intraoperatively. UTR value from dorsal stress radiography could be useful for evaluating DRUJ instability associated with distal radius fracture.     

Outcomes of surgically treated distal radius fractures associated with triangular fibrocartilage complex injury

Study DesignProspective cohort.IntroductionClinical studies that evaluate the correlation between associated lesions of the triangular fibrocartilage complex (TFCC) and outcome of distal radius fractures expressed with the patient-rated disability are missing. The purpose of this study was to evaluate the outcomes of distal radius fractures associated with or without an injury of the TFCC.MethodsPatients undergoing operative treatment for distal radius fracture were prospectively enrolled (n = 70). TFCC was examined by wrist arthroscopy and injuries classified according to Palmer. Comparative analyses were performed on 45 patients with TFCC injury (injured group) and 25 patients with intact TFCC (intact group). The outcome measures included the Patient-Rated Wrist Evaluation (PRWE) and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaires, 3 and 12 months after injury.ResultsTFCC was injured in 45 patients (64%). In patients with intact TFCC, mean total PRWE score was 27 (3 months) and 16 (12 months), compared to patients with TFCC injury with 40 (at 3 months) and 24 (at 12 months). Mean DASH scores were 26 and 13 at 3 and 12 months for the intact group and 39 and 27 for the injured group. PRWE and DASH results showed significant difference at 3 and 12 months when compared with Mann–Whitney test.DiscussionPRWE and DASH scores evaluation showed that patients with associated TFCC injury had greater pain and disability at 3 and 12 months after injury.ConclusionsDisability outcomes were worse in patients with distal radius fracture, where TFCC was injured. TFCC injuries are an important cofactor affecting the outcome of distal radius fractures.     

关节镜诊治关节内桡骨远端粉碎性骨折的软组织损伤

Objective To diagnose and evaluate soft tissue injuries in intra-articular fractures of the distal radius using arthroseopy. Methods Twenty young patients with displaced intra-articular fractures of distal radius were recruited in this prospective study. Three AO C2 and 17 C3 fractures were included. After arthroseopie examination fractures of distal radius were treated by external fixation with limited internal fixation or open plate fixation. Results Triangular fibrocartilage complex （TFCC） injury was found in 18 patients （90%） . Most were isolated Palmer type 1D injuries （67 % ）. Seapho-lunate ligament injury was found in two patients： one partial tear （grade H） and one complete tear （grade HI ）. Follow-ups ranged from 6 to 18 months. At the last follow-up, wrist function was excellent in one patient （6%）, good in eight（44% ） and fair in 11 （50%）. Conclusion TFCC injuries are common in intra-artieular fractures of the distal radius while injuries to seapho-lunate ligament are uncommon.     

A comparative study between longitudinal and "T" incisions for dorsal plating of the distal radius

A retrospective review of 24 patients with dorsal incisions for open reduction and internal fixation of Frykman VII/VIII distal radius fractures using a dorsal plate was performed. Half of them had a longitudinal incision while the other half had a T-shaped incision. No difference in the healing properties or wound morbidity could be demonstrated between the two groups. However, the T incision provided improved exposure of the distal radius and patient satisfaction with its cosmetic result was superior. The horizontal limb was well camouflaged within the transverse skin crease on the dorsal aspect of the wrist. The vertical limb did not extend into the dorsum of the hand and could, therefore, be hidden by appropriate clothing.     

Diagnostic and therapeutic significance of arthroscopy in distal radius fracture

Non-operative and minimal-invasive treatment of distal radius fractures have still a poor outcome. Although bony structures often heal acceptable, additional lesions of intraarticular ligamentous structures cause persistent pain and disability. Aim of the study was to present the diagnostic and therapeutic possibilities of arthroscopically assisted treatment of distal radius fractures. Diagnostic wrist arthroscopy found in 6 of 30 patients with distal radius fractures (23 AO type C fractures) a scapho-lunate ligament tear (20%) of which 3 had to be stabilized operatively. 18 patients (60%) presented with tears of the triangular fibrocartilage complex [Palmer classification: 1A (1); 1B (5); 1D (2); 1A, 1B (2); 1A, 1D (6); 1B, 1D (2)], which were repaired by arthroscopic shaving (n = 12), Kirschner wire stabilization of ulna head (n = 2) or arthroscopic suture (n = 3). Fractures were stabilized in most cases by combinations of canulated titan screws (3.0 mm) and Kirschner wires (n = 12). In 27 patients, the radial joint surface and the distal radio-ulnar joint could be reconstructed without any specific complications. Arthroscopic reduction of distal radius fractures allows minimal-invasive reconstruction of the joint surface, diagnoses relevant ligamentous tears and should applied with incongruencies of the joint surface greater than 2 mm and in widely dislocated fractures.     

The treatment of severely comminuted intra-articular fractures of the distal radius

Comminuted fractures of the distal end of the radius are caused by high-energy trauma and present as shear and impacted fractures of the articular surface of the distal radius with displacement of the fragments. The force of the impact and the position of the hand and carpal bone determine the pattern of articular fragmentation and their displacement and the amount and the extent of frequent concommitant ligament and carpal bone injury. The result of the osseous lesion in comminuted fractures was termed "pilon radiale", which emphasizes the amount of damage to the distal radius and the difficulties to be expected in restoring the articular congruity. Besides this the additional injury, either strain of disruption of the ligaments and the displacement of the carpus and/ or the triangular fibrocartilage complex will equally influence the functional outcome. This review will expand on the relevant anatomy, correct classification and diagnosis of the fracture, diagnostic tools and operative treatment options. Current treatment concepts are analysed with regard to actual literature using the tools of evidence based medicine criteria. A new classification of severely comminuted distal radius fractures is proposed using CT data of 250 complex intraarticular radius fractures. Finally a standardized treatment protocol using external fixation in combination with minimal invasive internal osteosynthesis is described.     

Plaster cast versus external fixation for unstable intraarticular Colles' fractures

This study compares 75 consecutive patients with Frykman Type VIII fractures of the distal forearm treated by primary external fixation with 32 patients who sustained similar injuries and were treated by closed reduction and cast immobilization. The latter group of patients served as an historical control. The two groups were similar with respect to injury and demographic characteristics. All fractures treated with external fixation remained well reduced and aligned, whereas 88% of those treated with casts had unsatisfactory alignment despite the fact that 30% had a second reduction. The external fixator group also had superior results with respect to functional outcome, range of motion, and grip strength.     

Wrist arthroscopy: principles and clinical applications.

With the development of better and smaller equipment, arthroscopy of the wrist offers the same benefits achievable with arthroscopy of the knee, shoulder, or elbow - not only diagnostic information but also a therapeutic option. Standardized techniques of performing wrist arthroscopy have been developed to evaluate the treat various wrist disorders, such as lesions of the triangular fibrocartilage complex, intra-articular distal radius fractures, and scaphoid fractures. Arthroscopy is now performed in the treatment of dorsal-wrist ganglion cysts and interosseous ligament disruptions, as well as for bone incisions, such as radial styloidectomy, distal ulnar excision (wafer procedure), and proximal-row carpectomy. Compared with other techniques, arthroscopic procedures, such as repair of the triangular fibrocartilage complex, demonstrate better results and improved localization of the injury with a low complication rate. In addition, arthroscopic procedures involve lesssurgical dissection, less postoperative pain, a shorter recovery time, and an earlier return to work for the patient.