腕关节镜掌侧入路的程式化建立

目的 介绍腕关节镜掌侧入路程式化建立的方法及其临床应用效果.方法 采用“由内向外”和“由外向内”相结合,1/2入路进入关节镜,3/4入路进入交换棒;6U入路进入关节镜,4/5入路进入交换棒的程式建立腕关节镜掌桡侧和尺侧入路.临床采用掌侧入路腕关节镜下处理桡骨远端骨折和腕尺侧痛患者25例,了解入路对手术的效用和副损伤.结果 通过腕关节镜掌侧入路,成功地进行了桡骨远端背侧骨折块的复位和内固定,对三角纤维软骨复合体的损伤进行评估和清创等手术,2例出现尺神经损伤症状,保守治疗后恢复,所有患者均无重要血管和肌腱的损伤.结论 程式化建立腕关节镜掌侧入路,安全、快捷、有效.对于腕部某些部位的疾病,掌侧入路腕关节镜手术是一种必要的选择.     

两种入路手术治疗腕舟骨骨折远期腕关节功能比较

目的 比较掌侧和背侧入路手术治疗腕舟骨不稳定骨折对远期腕关节功能的影响.方法 不稳定型腕舟骨骨折34例,通过掌侧和背侧入路手术治疗.结果 本组获随访10～12个月,腕舟骨骨折愈合后,腕关节活动范围及Krimmer评价相仿,无统计学差异.结论 掌侧或背侧入路治疗舟骨骨折对远期腕关节功能无差异,手术入路可根据不同医生手术习惯和熟练程度进行选择.     

腕关节镜掌侧入路的实验与临床研究

目的 报告腕关节镜掌侧入路的设计及初步应用结果.方法 腕关节镜掌桡侧入路定位在桡侧腕屈肌腱桡侧与舟骨结节交界处,掌尺侧入路定位在尺侧腕屈肌腱的尺侧缘、豌豆骨近侧0.5 cm处.对20具防腐腕关节以上离断标本进行解剖学研究,5具新鲜腕关节以上离断标本进行模拟镜下手术.2004年4月至2008年1月,共进行腕关节镜掌侧入路手术20例.男8例,女12例;年龄21～64岁,平均35.6岁.结果 掌侧入路与其周围的血管、神经等结构均有一定的安全距离.掌侧入路镜检可以清晰显示背侧关节囊、舟月骨间韧带的掌侧部分和月三角骨间韧带的掌侧部分.通过掌侧入路置入关节镜,背侧入路置入手术器械,可以更方便地处理腕关节腔背侧部分的病变.20例临床病例均未发生并发症,平均随访23.4(12～37)个月.末次随访时,腕关节背伸-掌屈活动度为134°±16°,桡尺偏活动度为39°±8°,旋前-旋后活动度为139°±18°.术前有2例疼痛为Ⅱ级,18例疼痛为Ⅲ级;末次随访时,11例疼痛为Ⅰ级,8例为Ⅱ级,1例为Ⅲ级;疼痛缓解显著(Z=31.2,P＜0.01).改良Garland和Werley评分为:优10例,良6例,可4例,优良率为80%.结论 腕关节镜掌侧入路是传统背侧入路的重要补充,具有安全性高、操作方便的优点.     

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。     

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...     

两种人路手术治疗腕舟骨骨折远期腕关节功能比较

目的比较掌侧和背侧人路手术治疗腕舟骨不稳定骨折对远期腕关节功能的影响。方法不稳定型腕舟骨骨折34例。通过掌侧和背侧人路手术治疗。结果本组获随访10-12个月,腕舟骨骨折愈合后,腕关节活动范围及Krimmer评价相仿,无统计学差异。结论掌侧或背侧人路治疗舟骨骨折对远期腕关节功能无差异。手术入路可根据不同医生手术习惯和熟练程度进行选择。     

掌侧与背侧入路切开复位内固定治疗AO23-C2型桡骨远端骨折的疗效比较

目的比较掌侧入路与背侧入路切开复位内固定治疗AO 23-C2型桡骨远端骨折的疗效。方法回顾性分析自2010-09—2013-09采用掌侧入路与背侧入路切开复位内固定治疗的28例AO 23-C2型桡骨远端骨折。掌侧入路17例均采用Henry切口,斜T形掌侧钢板内固定;背侧入路11例采用背侧纵形切口,双微型锁定钢板内固定。结果 28例均获得随访12~18个月,平均14.5个月。掌侧入路组手术时间较背侧入路组短,差异有统计学意义(P0.05);但2组术中出血量差异无统计学意义(P0.05)。2组骨折愈合时间、术后1年腕关节主动活动度差异均无统计学意义(P0.05);背侧入路组DASH评分优于掌侧入路组,差异有统计学意义(P0.05)。结论掌侧入路与背侧入路治疗AO 23-C2型桡骨远端骨折均可取得良好的疗效,手术入路的选择需要根据术前CT评估骨折块移位情况及术者的经验。     

掌侧与背侧入路切开复位内固定治疗C型桡骨远端骨折的比较研究

目的研究掌侧入路与背侧入路切开复位内固定治疗C型桡骨远端骨折的临床价值。方法选择2012年5月至2014年3月期间我院收治的70例C型桡骨远端骨折患者为研究对象,采用随机数字表法分为观察组和对照组各35例,观察组接受掌侧入路切开复位内固定治疗,对照组接受背侧入路切开复位内固定治疗。比较两组患者的内固定效果、腕关节功能以及并发症情况。结果术后1周、1个月以及3个月时,两组患者术后不同时间点的掌倾角、尺偏角、桡骨高度比较差异无统计学意义(t=0.075~0.215,P0.05);两组患者的腕关节功能差异无统计学意义(χ~2=0.108,P0.05);观察组患者并发症发生率低于对照组(χ~2=4.629,P0.05)。结论掌侧入路与背侧入路切开复位内固定治疗C型桡骨远端骨折均能取得相当的内固定效果以及腕关节功能改善效果,但掌侧入路手术能够更为有效的减少并发症的发生。     

经皮Herbert-Whipple空心螺钉固定治疗无移位腕舟骨骨折

目的探讨经皮掌背侧入路Herbert-Whipple空心螺钉固定治疗无移位腕舟骨骨折的手术方法及临床经验。方法经皮掌背侧入路治疗无移位腕舟骨骨折18例,B2和D2型均采用掌侧入路,B1型采用背侧入路。结果术后随访18例骨折均愈合,平均愈合时间8.3周。患手握力恢复至健侧的85%(80%～93%),患侧腕关节屈伸活动度恢复至健侧的80.3%(71%～95%)。患者于术后平均7.2周返回原工作岗位。结论新鲜的无移位舟骨骨折,术前常规给予舟骨CT三维重建以明确其骨折分型,早期经皮空心螺钉固定,术后早期开始功能锻炼,骨折愈合率高,功能恢复良好。     

比较掌侧和背侧入路锁定钢板内固定治疗不稳定性桡骨远端骨折的效果

目的比较掌侧和背侧入路锁定钢板内固定治疗不稳定性桡骨远端骨折的效果。方法根据不同手术入路将接受锁定钢板内固定治疗的94例不稳定性桡骨远端骨折患者分为2组,各47例。对照组采用背侧入路,观察组采用掌侧入路。回顾性分析患者的临床资料。结果术后2组患者的尺偏角、掌倾角均优于术前,差异有统计学意义(P0.05);但2组差异无统计学意义(P0.05)。观察组术后并发症发生率较对照组低,差异有统计学意义(P0.05)。术后随访1 a,依据Mcbridgi评分标准,观察组腕关节优良率为87.23%,对照组为85.11%,2组差异无统计学意义(P0.05)。结论掌侧入路与背侧入路锁定钢板内固定治疗不稳定性桡骨远端骨折,均有良好复位效果,但掌侧入路的并发症少,安全性较高。     

Clinical applications of volar portals in wrist arthroscopy

Volar portals for wrist arthroscopy have certain advantages over the standard dorsal portals for visualizing dorsal capsular structures as well as the palmar aspects of the carpal ligaments. The volar radial portal is relatively easy to use and is an ideal portal for evaluation of the dorsal radiocarpal ligament and the palmar aspect of the scapholunate interosseous ligament. The volar midcarpal portal may be considered as an occasional accessory portal for visualizing the palmar aspects of the capitate and hamate in cases of avascular necrosis or osteochondral fractures. The volar ulnar portal is especially useful for the viewing and debridement of palmar tears of the lunotriquetral ligament.     

Volar versus dorsal plating in the management of intra-articular distal radius fractures

PURPOSE: To compare the complications and functional and radiographic outcomes of volar and dorsal plating of intra-articular distal radius fractures. METHODS: This retrospective review included 34 patients found by searching a database of 350 patients treated for distal radius fractures. Inclusion criteria were (1) at least 1 year of follow-up data and (2) open reduction and internal fixation of a multifragmentary fragment intra-articular distal radius fracture with either a nonlocking volar or dorsal plate. Twenty patients were treated with a dorsal plate and 14 patients were treated with a volar nonlocking plate. Objective and subjective outcome parameters were compared between the 2 groups. Objective evaluations included wrist range of motion, grip strength, and preoperative and postoperative radiographic parameters (radial inclination, palmar tilt, ulnar variance, fracture pattern). Subjective evaluations were performed using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score and the Gartland and Werley score. RESULTS: Volar plating resulted in a significantly better Gartland-Werley score compared with dorsal plating. There were no significant differences in the DASH score.Volar collapse was documented in 5 of the 20 patients in the dorsal plating group, which resulted in a mild loss of pronation compared with the volar plating group. No collapse occurred in the volar plating group. In addition the difference in the percentage of wrist range of motion compared with the contralateral wrist was not significant. Dorsal plating was associated with a ruptured extensor indicis tendon in 1 patient; secondary surgical procedures were required in 4 patients (tenolyses and radial styloidectomy). Volar plating was associated with median nerve neuropathy in 2 patients and intersection syndrome in one. CONCLUSIONS: Although both groups of patients had similar DASH scores the functional outcome in terms of Gartland and Werley scores was better in the volar plating group. In addition there was a higher rate of volar collapse and late complications in the dorsal plating group compared with the volar plating group. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level III.     

Volar portals in wrist arthroscopy

Volar portals for wrist arthroscopy have certain advantages over the standard dorsal portals for visualizing dorsal capsular structures as well as the palmar aspects of the carpal ligaments. The volar radial (VR) portal is relatively easy to use and is an ideal portal for evaluation of the dorsal radiocarpal ligament (DRCL) and the palmar aspect of the scapholunate interosseous ligament. The volar midcarpal portal may be considered as an occasional accessory portal for visualizing the palmar aspects of the capitate and hamate in cases of avascular necrosis or osteochondral fractures. The volar ulnar (VU) portal is especially useful for the viewing and debridement of palmar tears of the lunotriquetral ligament. Copyright © 2002 by the American Society for Surgery of the Hand     

A benefit of the volar approach for wrist arthroscopy

We reviewed 230 cases of wrist arthroscopy using a volar approach and evaluated its advantage in various wrist disorders. In general, a dorsal approach has been preferred in wrist arthroscopy. The volar approach has been avoided because of the presence of significant structures, such as radial and ulnar arteries, their venae comitantes, median and ulnar nerves, and flexor tendons. However, we can access the wrist joint securely using the volar approach through the tendon sheath of the flexor carpi radialis. Through this approach, we can adequately visualize the dorsal rim fragment of the intra-articular fracture of the distal radius, dorsal synovial proliferation of the rheumatoid wrist, and volar segment tear of the scapholunate and lunotriquetral interosseous ligaments. We had no complications with wrist arthroscopy using the volar approach in 230 patients. The volar approach for wrist arthroscopy is a valuable procedure to evaluate and treat various wrist disorders.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 4 (April), 2003: pp 440–445     

Volar neutralization plate fixation of dorsally displaced distal radius fractures

Open reduction and volar neutralization plate fixation avoids problems associated with dorsal plate fixation (eg, extensor tenosynovitis and tendon rupture) and minimizes the necessity for secondary plate removal. Volar plating is a useful technique for treating dorsally displaced distal radius fractures with minimal scarring, infrequent bone grafting, and safe early wrist mobilization.     

掌侧单切口联合背侧入路治疗桡骨远端粉碎性骨折25例报告

目的探讨经掌侧单切口联合背侧入路治疗桡骨远端粉碎性骨折的临床疗效。方法2010年6月-2012年10月对25例不稳定桡骨远端粉碎性骨折采用掌侧单切口、掌背侧联合人路放置掌侧锁定加压钢板固定。结果手术时间62—115min。平均84min。术中出血量10—80ml,平均22ml。术中桡动脉挫伤1例,术后B超检查未形成血管栓塞及血管瘤;伸肌腱粘连1例,经局部理疗及功能锻炼,术后5个月好转。25例随访6～28个月,平均14．1月。术后6～13周（平均8．3周）骨折愈合。按Gartland和Werley计分法评价,术后第24周腕关节功能优良率92．0％（23／25）;放射学评价按Lidstrom评分标准,桡骨关节面恢复优良率88．0％（22／25）。结论对桡骨远端粉碎性骨折,采用掌侧单切口、掌背侧联合入路的方法能清晰地同时显露桡骨远端掌背侧关节面,避免背侧辅助小切口,疗效满意。     

Distal radioulnar joint arthroscopy and the volar ulnar portal

Pain on the ulnar side of the wrist remains poorly understood. As attention has shifted toward the myriad causes of ulnar-sided wrist pain, the utility of viewing the wrist from a volar ulnar (VU) perspective has emerged. Lunotriquetral ligament tears have been implicated in the pathogenesis of volar intercalated segmental instabilities. They often originate in the palmar subregion, which is most important for maintaining stability. These tears are difficult to visualize through the 4, 5, or 6R portals. They are well seen through a VU portal, and the direct line of sight facilitates debridement. The VU portal has potential use in the arthroscopic diagnosis and treatment of patients with injuries to the ulnar sling mechanism. It aids in triangular fibrocartilage repairs especially those involving the dorsal aspect between the ulnar styloid and the radial insertion, because the proximity of the 4, 5, and 6R portals makes triangulation of the instruments difficult. Although arthroscopy of the dorsal aspect of the distal radioulnar joint has been well described, it has largely remained a curiosity, with few clinical indications. Recent biomechanical studies have highlighted the importance of the deep attachment of the triangular fibrocartilage complex in maintaining distal radioulnar joint stability. The volar distal radioulnar portal is useful for assessing the foveal attachment. It may be used where there is the suspicion of a peripheral triangular fibrocartilage detachment due to a loss of its normal tension despite the lack of a visible tear during radiocarpal arthroscopy. The judicious use of these portals deserves consideration for inclusion as part of a thorough arthroscopic examination of selected patients with ulnar-sided wrist pain.     

Interest in wrist arthroscopy for treatment of articular fractures of the distal radius: report of 27 cases]

We report our results of treatment of intra articular distal radius fracture assisted by wrist arthroscopy. Twenty six patients (15 men and 11 women) were treated using this technique. All the patients were operated on under regional anaesthesia, the elbow flexed to 90 degrees, and in-line traction applied using "Japanese" fingers traps (4 to 6 kgs). After articular cleansing, reduction under arthroscopic and fluoroscopic control was carried out using K-wires. All fractures were intra articular and in four cases of fractures with four fragments, it was necessary to combine a volar plate with the K-wires. There were 21 associated ligament injuries (seven TFCC tears, four lunotriquetral ligament injuries and ten scapholunate injuries of which four necessitated pinning). Our average follow-up time was 16 months (6-26 months). There was absence of pain in 23 cases and the results were good for wrist motion and strength. We did not experienced any severe secondary displacement. Eighteen excellent, seven good results and one average result were obtained. The quality of these functional and anatomical results seems to be directly linked to the quality of reduction obtained under arthroscopy and the quality of internal fixation carried out under traction.     

掌侧LCP结合Kapandji技术治疗背侧不稳定桡骨远端关节内骨折初步报道

目的 探讨掌侧锁定加压钢板(locking compression plate,LCP)结合Kapandji技术治疗背侧不稳定桡骨远端关节内骨折的方法 及疗效.方法 背侧不稳定桡骨远端关节内骨折患者43例,男17例,女26例;年龄42～65岁,平均57岁.按AO/ASIF分型,C1型26例,C2型16例,C3型1例.采用掌侧LCP结合Kapandji技术进行治疗.在Stewart等改良的Sarmiento评分基础上再次进行改良,从掌倾角、尺偏角、桡骨短缩和关节面台阶方面对桡骨远端影像学进行评估;采用Gartland-Werley功能评分对腕关节功能进行评估.结果 所有患者均获得随访,随访时间16～47个月,平均27个月.掌倾角由术前-19.3°±11.2°改善至术后8.1°±3.2°,尺偏角由术前-13.6°±4.1°改善至术后18.0°±8.2°,桡骨短缩由术前(6.2±2.8)mm改善至术后(0.2±0.2)mm,关节面塌陷由术前(5.5±4.3)mm改善至术后(0.1±0.2)mm.在Stewart等改良的Sarmiento评分基础匕再次进行改良的评分,优34例,良9例;Gartland-Werley功能评分,优18例,良22例,可3例.结论 掌侧LCP结合Kapandji技术是治疗背侧不稳定桡骨远端关节内骨折的一种有效方法 ,可有效防止复位丢失、肌腱激惹等并发症,减少结构性植骨及行早期关节活动.     

尺骨茎突骨折对桡骨远端骨折手术疗效及腕关节功能的影响

目的观察尺骨茎突骨折对桡骨远端骨折手术疗效及腕关节功能的影响。方法对64例不稳定桡骨远端骨折进行回顾性分析,选择AO分型为A型和B型的不稳定桡骨远端骨折患者,均行切开复位T型桡骨远端锁定钢板内固定治疗,尺骨茎突骨折未作特殊处理,将所有资料按照未合并尺骨茎突骨折组、尺骨茎突骨折(体部骨折)Ⅰ型组及尺骨茎突骨折(基底部骨折)Ⅱ型组分组进行整理分析,记录病例AO分型及术前、术后6个月和术后1年的X线片测量结果 ,按照Bunger提出的解剖学评分(掌倾角、尺偏角、桡骨茎突高度)进行解剖学评估,同时进行GartlandWerly评分。结果随访时间为7~12个月,平均11个月,64例桡骨远端骨折均愈合。未合并尺骨茎突骨折组、尺骨茎突骨折Ⅰ型组及Ⅱ型组术前、术后6个月及术后1年解剖学评分差异无统计学意义,未合并尺骨茎突骨折组与尺骨茎突骨折Ⅰ型组Gartlant-Werley评分、优良率差异无统计学意义。但未合并尺骨茎突骨折组与尺骨茎突骨折Ⅱ型Gartlant-Werley评分、优良率差异有统计学意义,尺骨茎突骨折Ⅰ型组与Ⅱ型组相比,Gartlant-Werley评分、优良率差异有统计学意义。结论尺骨茎突骨折与否及分型对桡骨远端骨折术后解剖学评分无影响,尺骨茎突体部骨折对腕关节功能无影响,但尺骨茎突基底部骨折对腕关节功能有一定影响,值得进一步研究。