Liebort法治疗下尺桡关节分离疗效分析

下尺桡关节分离是易被忽略的脱位之一。传统治疗多以非手术治疗为主。近年来在探索损伤机制、损伤分类等研究基础上,我们应用Liebort法治疗下尺桡关节分离9例,取得了较好的临床效果。现将术后2年以上的病例加以总结,报告如下: 1 临床资料 1.1 一般资料 本组9例中,男7例,女2例;年龄18、27岁,平均21.5岁。外伤性下尺桡关节分离5例,病因不明2例,先天性2例。自发病到手术时间平均15.5个月(先天性者自出现症状时算起)。下尺桡关节背侧有持续疼痛及压痛,突然旋转或用力对抗旋转时疼痛加重,旋转有不同程度障碍,有时可听到响声,下尺桡关节有时不稳。 1.2 手术方法和骤 取腕背横向切口,长约4～5cm。按切口方向切开筋膜和腕背韧带,纯性向深部分离,可从骨膜下将筋膜管掀起,连同桡侧腕长、短伸肌腱一起向桡侧牵开。用同法处理指总伸肌腱,将其向尺侧牵开,显露关节。“U”形切开关节囊,最好从桡骨背侧面凿下薄层骨质,形成一块骨—骨膜瓣,再向尺侧翻开。显露关节后,在桡骨加尺骨下端排列钻孔。共6孔,桡骨上4孔,尺骨上2孔。纵看3排6孔,横看2排3孔,孔底相通。取适当长度筋膜条,使其穿过尺骨2骨孔,交叉后,通过桡骨2排骨孔穿出。旋转下尺桡关节,使其复位,抽紧筋膜条,缝合固定。筋膜条可取自髂胫束,掌长肌腱或趾长伸     

Sauve-Kapandji手术治疗合并桡骨骨不连的桡尺远侧关节脱位1例

2002年2月我院曾收治1例合并桡骨骨不连的桡尺远侧关节脱位患者,采用Sauve-Kapandji手术治疗取得了满意的疗效,报道如下。1病例资料患者,男,26岁。于2001年不慎摔倒,左腕部着地,曾到外院拍片后诊断为左桡骨远端骨折,行切开复位钢板内固定术,1年后拍片,取出钢板(术前及术中细节不详)后左上臂肿胀、疼痛、功能受限来我院。局部检查:左前臂远端肿胀,远端桡侧可触及异常活动,尺骨茎突向背侧脱位。首先取前臂远端背侧纵切口,逐层切开暴露桡侧腕长、腕短伸肌腱及拇长伸肌腱,沿肌间隙暴露桡骨骨折端,清除硬化骨及髓腔,直视下复位后常规取髂骨条植…     

尺骨茎突骨折伴下尺桡关节脱位1例

尺骨茎突骨折伴下尺桡关节完全脱位的病例在腕关节损伤中并不多见,作者于2002年7月诊治1例,现报道如下。1病例资料患者,女,57岁,农民,于2002年7月1日被重物砸伤右前臂,造成远端疼痛、畸形,3小时后来院。查体:右前臂远端宽度变窄,掌侧隆起,尺侧腕屈肌腱与掌长肌腱之间可触及脱位之尺骨小头,按压无异常活动,无尺神经及正中神经损伤症状。X线:右尺骨茎突骨折,尺骨小头向桡掌侧完全脱位。即行手法整复,极度屈曲腕关节,并向尺背侧按压脱位之尺骨小头,使尺骨小头滑过松驰的尺侧腕屈肌腱,解除交锁,而后背伸腕关节,向背侧推挤尺骨小头,使其与尺骨茎…     

带骨间背侧动脉蒂的尺骨远端骨块移植治疗尺,桡骨骨不连接

在解剖研究基础上设计出带村问背侧动脉蒂的尺骨远端骨块移植治疗尺、桡骨骨不连接。通过对７０侧尸体上肢解剖观察，发现骨间背侧动脉在远侧段发出２～３个骨膜支营养尺骨远端。临床应用７例，术中紧贴尺侧腕伸肌桡侧．在其深面游离骨间背侧动脉连同周围１．０ｃｍ深筋膜，直至见到进入民骨的骨膜支，切取风骨远端，将此带血管蒂的尺骨块移植至近端尺、桡骨骨缺损处．随访６～１２个月，３．５个月时均达到骨性愈合。骨块切取后保留了尺骨的连续性和下尺桡关节的完整性，不影响前臂及腕关节的运动。我们为治疗尺、桡骨骨不连接提供了一种新的有效方法。     

累及桡尺远侧关节不稳定的尺骨茎突骨折手术治疗

目的 介绍累及桡尺远侧关节不稳定的桡骨远端合并尺骨茎突骨折的手术指征和治疗方法.方法 2005年1月至2009年6月,对12例桡骨远端骨折合并尺骨茎突骨折的患者,采用克氏针结合张力带钢丝固定尺骨茎突,同时采用骨锚修复下尺桡韧带深层结构在尺骨隐窝的止点,从而稳定桡尺远侧关节.结果 术后12例桡骨远端骨折及尺骨茎突骨折均愈合,术后随访时间为6～18个月.按改良的Mayo腕关节评分标准评定:优4例,良5例,中2例,差1例.结论 尺骨茎突在桡尺远侧关节稳定中起着重要作用,对累及下尺桡韧带结构损伤的尺骨茎突骨折进行固定并重建韧带对稳定桡尺远侧关节有较为重要的作用.     

三角纤维软骨复合体解剖及生物力学研究

目的从解剖完整的腕关节入手,阐明三角纤维软骨复合体各组成部分的解剖特点,评估三角纤维软骨复合体(TFCC)对于维持远侧桡尺关节稳定的重要性。方法对8个新鲜解冻的腕关节和6个经甲醛浸泡的腕关节进行显微解剖。同时对影响远侧桡尺关节稳定性的因素作了初步的评估。前臂中旋位,垂直于尺骨予20N拉力下测量尺骨相对于桡骨的位移,然后先后切断掌背侧桡尺韧带,测量尺骨相对于桡骨的位移变化。结果发现掌背桡尺韧带由三角纤维软骨盘外周增厚而成,止于尺骨茎突基底部,是维持远侧桡尺关节稳定性的主要因素之一,切断掌背侧桡尺韧带会导致远侧桡尺关节明显不稳。结论TFCC由三角纤维软骨盘、掌背侧桡尺韧带、尺骨月骨韧带、尺骨三角骨韧带、尺侧腕伸肌下腱鞘、半月板同源物、尺侧囊组成。掌背桡尺韧带是维持远侧桡尺关节稳定性的主要因素之一,掌背侧桡尺韧带损伤会导致远侧桡尺关节明显不稳。     

远端桡尺关节半脱位的CT检查

目的探讨通过 CT检查提高对远端桡尺关节半脱位的诊断率。方法对 56例经 X线检查可疑为远端桡尺关节半脱位的患者（男 36例,女 20例）行双侧远端桡尺关节旋前、旋后位 CT横断扫描。应用 Nakamura的改良桡尺线方法进行测量,经过双侧对比确定尺骨头掌侧或背侧半脱位。结果在 56例 X线检查拟诊为远端桡尺关节半脱位的患者中,尺骨头掌侧半脱位 10例;尺骨头背侧半脱位 15例;另有 2例为尺骨头背侧半脱位,经与健侧对比确定为假阳性。结论通过 CT检查诊断远端桡尺关节半脱位,可减少 X线检查由于难以达到标准投照位置所产生的假阳性,从而提高对远端桡尺关节半脱位的诊断率。对曾有腕关节外伤史或逐渐加重的腕部疼痛及远端桡尺关节活动受限者, CT检查是诊断远端桡尺关节半脱位较为有效的方法。     

掌长肌腱转位修复桡尺远侧关节脱位

从解剖学角度证实，应用掌长肌腱转位修复桡尺侧关节脱位的机理。方法：测定３０侧上肢标本中掌长肌腱各段的宽度，厚度；对９条新鲜掌长肌腱进行拉伸试验。临床应用３０例，将掌长肌腱近端以：“８”字形穿过桡骨及尺骨骨孔，紧缩分离的桡尺远侧关节后固定于掌筋膜。     

韧带解剖重建术治疗慢性远尺桡关节不稳定

 目的介绍自体掌长肌腱移植、远尺桡韧带解剖重建的适应证、手术方法 及治疗慢性远尺 桡关节(distal radioulnar joint, DRUJ)不稳定的初期随访结果 。方法 2008年 10月至 2009年 6月, 应用 自体掌长肌腱移植、远尺桡韧带解剖重建术治疗 6例慢性 DRUJ不稳定患者。平均年龄 22岁。男 4例, 女 2例。术中取腕背第四、五伸肌鞘管间纵行切口。切开鞘管, 显露 DRUJ背侧部分。横野L冶形切开远尺 桡背侧关节囊, 显露 DRUJ和三角纤维软骨盘。于桡骨远端尺背侧, 距离月骨窝和乙状切迹各约 5 mm 处钻孔。在尺侧腕屈肌腱桡侧做掌侧纵行切口, 切取全长掌长肌腱, 将其一端通过桡骨隧道穿至掌侧, 再用止血钳经三角纤维软骨盘下方透过掌侧关节囊, 将其引至背侧。在尺骨颈和茎突隐窝之间钻孔。将 肌腱两个断端经尺骨隧道引至尺骨颈处, 再把其中一端绕过尺骨颈。将前臂置于中立位, 抽紧缝合肌腱。 术后长臂石膏固定前臂于中立位。 4周后更换为前臂石膏, 继续制动 4周。结果 所有患者术后均获得 9~24个月随访, 平均 14个月。术后没有感染及感觉神经支损伤等并发症。疼痛减轻, 握力增加。采用改 良 Mayo评分评估腕关节功能: 术前平均 69分, 术后平均 95分。 5例患者对手术结果 满意。结论 韧 带解剖重建术适用于无骨性关节炎的慢性 DRUJ不稳定, 术后腕关节功能改善明显。     

远侧桡尺关节脱位及诊治进展

远侧桡尺关节 (ｄｉｓｔａｌｒａｄｉｏｕｌｎａｒｊｏｉｎｔＤＲＵＪ)脱位可引起腕部疼痛 ,腕部无力 ,前臂旋转运动受限 ,腕关节不稳 ,指伸肌腱断裂等障碍〔1～ 3〕。近年来随着对ＤＲＵＪ脱位认识的日益提高 ,它已成为腕部损伤的一个重要课题。本文就ＤＲＵＪ的生物力学、损伤机制、诊断和治疗进展作一综述。1　远侧桡尺关节的生物力学远侧桡尺关节是由尺骨头和桡骨尺侧“Ｓ”形切迹 ,尺骨头和三角软骨构成的双枢轴关节 ,由于桡骨和手的旋转都以尺骨为轴 ,因此ＤＲＵＪ在手腕功能解剖中显得特别重要〔4〕。腕关节的旋转运动主要源于前臂的…     

Excision of the distal ulna in rheumatoid arthritis

Resection of the ulna is an effective operation in the treatment of rheumatoid disorders of the distal radioulnar joint. Tenosynovectomies of the overlying extensor tendons and synovectomy of the joint are integral parts of the procedure. Following resection, the ulna usually remains in alignment with the radius, although some dorsal displacement is common. Restoring stability to the ulna as well as reconstructing a new sheath for the extensor carpi ulnaris can be accomplished in most cases by using the extensor retinaculum. In those cases where the retinaculum has been destroyed by the disease process or when the distal ulna is severely displaced, stability can be restored using the extensor carpi ulnaris for a tenodesis.     

Dorsal dislocation of the ulnar styloid and extensor carpi ulnaris tendon into the distal radioulnar joint: the empty sulcus sign

Two cases of distal radioulnar joint (DRUJ) disruption and diastasis secondary to distal radial fractures were associated with displacement of the ulnar styloid and extensor carpi ulnaris (ECU) into the DRUJ. Both cases had a palpable empty ECU tendon sulcus. In one case surgical exploration revealed that the ulnar styloid, triangular fibrocartilage, and extensor carpi ulnaris tendon had dislocated into the DRUJ as a unit. The end result was good. In the second case lack of recognition and reduction of the ECU tendon and ulnar styloid led to persistent subluxation and diastasis. The end result was poor. Early recognition of the dislocation of the ulnar and ECU into the DRUJ and their significance may avoid poor results.     

Extensor carpi ulnaris and flexor carpi ulnaris tenodesis of the unstable distal ulna

A procedure for stabilizing the distal ulna using the extensor carpi ulnaris and flexor carpi ulnaris is described. Seven patients who had sustained posttraumatic distal ulnar dorsal instability and articular degeneration and one patient with instability caused by rheumatoid arthritis were operated on. All eight obtained stable ulnae with mean motion of 62 degrees of supination and 86 degrees of pronation (mean increase of 32 degrees of supination and 43 degrees of pronation). Follow-up averaged 28 months (range, 18 to 63 months). The tenodesis, using a weave of a distally-based slip of flexor carpi ulnaris and a proximally-based slip of extensor carpi ulnaris combined with a Darrach procedure, is a reliable, reproducible salvage procedure for stabilizing the degenerated distal radioulnar joint and for salvaging the symptomatic unstable ulna after excessive distal ulna resection.     

Complex volar dislocation of the distal radioulnar joint in a Galleazi variant associated with interposition of the ulnar neurovascular bundle

Galleazi type fracture dislocations are sometimes associated with complex dorsal dislocation of the distal radioulnar joint due to interposition of the extensor carpi ulnaris tendon. We present the first reported case of complex volar distal radioulnar joint dislocation in a Galleazi variant associated with interposition of the ulnar neurovascular bundle.     

Surgical correction of recurrent volar dislocation of the distal radioulnar joint. A case report

Recurrent volar dislocation of the distal ulna is an unusual injury. The role of various anatomic structures in providing stability of the distal radioulnar joint is controversial. Surgical reconstruction of the distal radioulnar joint was performed in a 25-year-old woman. A sling procedure was performed along with reconstruction of the fibrous osseous canal of the extensor carpi ulnaris (ECU). The ECU appears to play a role in stabilizing the distal radioulnar joint. When dislocation of the ECU tendon is noted intraoperatively, reconstruction of the fibrous osseous canal should be done.     

Irreducible dislocation of the distal radioulnar joint

Although dislocation of the distal radioulnar joint is commonplace in association with fractures of the radial shaft, irreducible dislocation has previously been considered to be rare. In the only three previously reported cases the tendon of the extensor carpi ulnaris blocked reduction of the distal radioulnar joint in Galeazzi injuries. The cases presented in this report show that other tendons may be involved, and that the injury may occur even when the ulna is broken. It is likely that the injury described is more common than is realized and is usually overlooked.     

Open repair of the ulnar disruption of the triangular fibrocartilage complex with double three-dimensional mattress suturing technique

Open repair technique of the ulnar disruption of the triangular fibrocartilage complex is described. This technique is indicated for a fresh or a relatively fresh (less than 1 year after the initial injury) ulnar foveal detachment tear, horizontal tear, and proximal slit tear of the triangular fibrocartilage complex, all of which are accompanied by severe dorsal, palmar, or multidirectional instability of the distal radioulnar joint. A chronic tear greater than 1 year from initial injury and a fresh triangular fibrocartilage complex tear without distal radioulnar joint instability, such as central slit tear, are excluded from our indications. A dorsal C-shaped skin incision, a longitudinal incision of the radial edge of the extensor carpi ulnaris subsheath and the dorsal distal radioulnar joint capsule, exposes the distal radioulnar joint. A small, 5-mm longitudinal incision at the origin of the radioulnar ligament exposes its fovea detachment and/or the proximal slit tear of the triangular fibrocartilage complex. The disrupted radioulnar ligament is sutured in a pullout fashion to the ulna with a 3-dimensional double mattress technique through 2 bone tunnels that is precisely made at the central portion of the fovea with 1.2-mm K-wire. An additional horizontal mattress suture is used for closure of the small incision made at the radioulnar ligament, then the extensor carpi ulnaris is repaired. This open-repair technique is complex and requires precise technical skills; however, early results have been more rewarding than the conservative treatment.     

Radioulnar convergence after distal ulnar resection: mechanical performance of two commonly used soft tissue stabilizing procedures

Resection of the distal ulna (Darrach operation) is a common method for salvaging the arthrotic distal radioulnar joint (DRUJ). However, problems have been reported with this procedure due to residual instability and radioulnar convergence. As a result, several methods of soft tissue stabilization for the unstable distal ulna have been developed. Although their clinical efficacy has been reported, biomechanical investigations of these procedures have not been reported. The purpose of our study was to evaluate the dynamic effects on radioulnar convergence and dorsal-palmar displacement of three procedures: the Darrach procedure, a pronator quadratus interposition flap and an extensor and flexor carpi ulnaris tenodesis. We tested 7 fresh-frozen cadaver upper extremities using a dynamic computer-controlled device that generated forearm rotation with physiologic loading of relevant muscles. Displacement data concerning the ulna relative to the radius through the range of forearm rotation was collected for 4 experimental conditions: intact, distal ulna resection alone, distal ulna resection with pronator quadratus interposition and distal ulna resection with extensor and flexor carpi ulnaris tenodesis. Distal ulna resection altered the kinematics, most predictably creating a convergence of the radius towards the ulna. Anteroposterior translations in each loading condition could be detected as well. The interposition of the pronator quadratus muscle or tenodesis with the extensor and flexor carpi ulnaris tendons did not reduce the radioulnar convergence created by resection of the distal ulna.     

Radioulnar convergence after distal ulnar resection

Resection of the distal ulna (Darrach operation) is a common method for salvaging the arthrotic distal radioulnar joint (DRUJ). However, problems have been reported with this procedure due to residual instability and radioulnar convergence. As a result, several methods of soft tissue stabilization for the unstable distal ulna have been developed. Although their clinical efficacy has been reported, biomechanical investigations of these procedures have not been reported. The purpose of our study was to evaluate the dynamic effects on radioulnar convergence and dorsal-palmar displacement of three procedures: the Darrach procedure, a pronator quadratus interposition flap and an extensor and flexor carpi ulnaris tenodesis. We tested 7 fresh-frozen cadaver upper extremities using a dynamic computer-controlled device that generated forearm rotation with physiologic loading of relevant muscles. Displacement data concerning the ulna relative to the radius through the range of forearm rotation was collected for 4 experimental conditions: intact, distal ulna resection alone, distal ulna resection with pronator quadratus interposition and distal ulna resection with extensor and flexor carpi ulnaris tenodesis. Distal ulna resection altered the kinematics, most predictably creating a convergence of the radius towards the ulna. Anteroposterior translations in each loading condition could be detected as well. The interposition of the pronator quadratus muscle or tenodesis with the extensor and flexor carpi ulnaris tendons did not reduce the radioulnar convergence created by resection of the distal ulna.     

Radioulnar convergence after distal ulnar resectionMechanical performance of two commonly used soft tissue stabilizing procedures

Resection of the distal ulna (Darrach operation) is a common method for salvaging the arthrotic distal radioulnar joint (DRUJ). However, problems have been reported with this procedure due to residual instability and radioulnar convergence. As a result, several methods of soft tissue stabilization for the unstable distal ulna have been developed. Although their clinical efficacy has been reported, biomechanical investigations of these procedures have not been reported. The purpose of our study was to evaluate the dynamic effects on radioulnar convergence and dorsal-palmar displacement of three procedures: the Darrach procedure, a pronator quadratus interposition flap and an extensor and flexor carpi ulnaris tenodesis. We tested 7 fresh-frozen cadaver upper extremities using a dynamic computer-controlled device that generated forearm rotation with physiologic loading of relevant muscles. Displacement data concerning the ulna relative to the radius through the range of forearm rotation was collected for 4 experimental conditions: intact, distal ulna resection alone, distal ulna resection with pronator quadratus interposition and distal ulna resection with extensor and flexor carpi ulnaris tenodesis. Distal ulna resection altered the kinematics, most predictably creating a convergence of the radius towards the ulna. Anteroposterior translations in each loading condition could be detected as well. The interposition of the pronator quadratus muscle or tenodesis with the extensor and flexor carpi ulnaris tendons did not reduce the radioulnar convergence created by resection of the distal ulna.