Njengamanje, kunezindlela ezahlukene zokwelapha ukuphuka kwe-distal radius, njengokufakwa kwe-plaster, ukunciphisa okuvulekile kanye nokufakwa kwangaphakathi, uhlaka lokufakwa kwangaphandle, njll. Phakathi kwazo, ukufakwa kwe-volar plate kungathola umphumela owanelisayo, kodwa kunemibiko ezincwadini yokuthi izinkinga zayo ziphezulu ngamaphesenti angu-16. Kodwa-ke, uma ipuleti lensimbi likhethwe kahle, ukwanda kwezinkinga kungancishiswa ngempumelelo. Leli phepha lifingqa kafushane izici, izinkomba, iziphambeko, kanye namasu okuhlinzwa okwelashwa kwe-volar plate yokuphuka kwe-distal radius.
1. Kunezinzuzo ezimbili eziyinhloko zepuleti eliseceleni lesundu
A. Inganciphisa ingxenye yamandla okugoba. Ukuqinisa ngezikulufo zokuqinisa ezigobile kusekela ingxenye ekude futhi kudlulisele umthwalo ku-radial shaft (Isithombe 1). Ingathola ukwesekwa kwe-subchondral ngempumelelo enkulu. Lolu hlelo lwepuleti alukwazi nje ukulungisa ngokuzinzile ukuphuka kwe-distal intra-articular, kodwa futhi lungabuyisela ngempumelelo isakhiwo somzimba sethambo le-subchondral intra-articular ngokusebenzisa ukuqina kwe-peg/screw "okumila njengefeni". Ezinhlotsheni eziningi zokuphuka kwe-distal radius, lolu hlelo lophahla lunikeza ukuzinza okwandisiwe okuvumela ukunyakaza kwasekuqaleni.
Isithombe 1, a, ngemva kokwakhiwa kabusha kwe-distal radius fracture ejwayelekile enezinhlangothi ezintathu, naka izinga lokucindezelwa kwe-dorsal; b, ukunciphisa okubonakalayo kokuqhekeka, isici kumele silungiswe futhi sisekelwe yipuleti; c, umbono ohlangene ngemva kokulungiswa kwe-DVR, umcibisholo ubonisa ukudluliselwa komthwalo.
B. Umthelela omncane ezicutshini ezithambile: ukufakwa kwe-volar plate kungaphansi kancane komugqa wamanzi, uma kuqhathaniswa ne-dorsal plate, kunganciphisa ukucasuka kwe-tendon, futhi kunesikhala esitholakalayo esengeziwe, esingagwema ukuxhumana okuqondile kwe-implant kanye ne-tendon ngempumelelo. Ngaphezu kwalokho, iningi le-implant lingambozwa yi-pronator quadratus.
2. Izinkomba kanye ne-contraindications yokwelapha i-distal radius nge-volar plate
a.Izinkomba: Uma ukwehluleka kokunciphisa ukuqhekeka kwe-extra-articular okuvaliwe, kuvela izimo ezilandelayo, njengokugoba kwe-dorsal okungaphezu kwama-20°, ukucindezela kwe-dorsal okungaphezu kwama-5mm, ukufinyela kwe-distal radius okungaphezu kwama-3mm, kanye nokufuduka kwe-distal fracture fragment okungaphezu kwama-2mm; Ukufuduka kwe-internal fracture kungaphezu kwama-2 mm; ngenxa yobuningi obuphansi bamathambo, kulula ukubangela ukufuduka kabusha, ngakho-ke kufaneleka kakhulu kubantu asebekhulile.
b. Izimo ezingahambisani nazo: ukusetshenziswa kwemithi yokubulala izinzwa yendawo, izifo ezithathelwanayo zendawo noma zomzimba, isimo sesikhumba esibi ohlangothini lwe-volar lwesandla; isisindo samathambo kanye nohlobo lokuphuka endaweni yokuphuka, uhlobo lokuphuka komgogodla njengokuphuka kukaBarton, ukuphuka nokuqhekeka kwamalunga e-radiocarpal, i-radius elula yokuphuka kwenqubo ye-Styloid, ukuphuka okuncane kwe-avulsion kwe-volar margin.
Ezigulini ezinezimo ezinzima njengokwaphuka okukhulu kwe-intra-articular comminute noma ukulahlekelwa amathambo okukhulu, izazi eziningi azincomi ukusetshenziswa kwama-volar plates, ngoba ukwaphuka okunjalo kwe-distal kuthambekele ekuhlaselweni yi-vascular necrosis futhi kunzima ukuthola ukunciphisa komzimba. Ezigulini ezinezingcezu eziningi zokuphuka kanye nokufuduka okukhulu kanye ne-osteoporosis enzima, i-volar plate kunzima ukusebenza. Kungase kube nezinkinga ngokusekelwa kwe-subchondral ekuqhekekeni kwe-distal, njengokungena kwesikulufu emgodini wamalunga. Izincwadi zakamuva zibike ukuthi lapho amacala angu-42 okuqhekeka kwe-intra-articular ephathwa ngama-volar plates, akukho zikulufu ze-articular ezangena emgodini wamalunga, okwakuhlobene kakhulu nendawo yama-plates.
3. Amakhono okuhlinza
Odokotela abaningi basebenzisa ukulungiswa kwe-volar plate ukuze kuphuke i-distal radius ngezindlela namasu afanayo. Kodwa-ke, ukuze kugwenywe ngempumelelo ukwenzeka kwezinkinga zangemva kokuhlinzwa, kudingeka indlela enhle kakhulu yokuhlinzwa, isibonelo, ukunciphisa kungatholakala ngokukhulula ukucindezelwa kwe-fracture block nokubuyisela ukuqhubeka kwethambo le-cortical. Ukulungiswa kwesikhashana ngezintambo ze-Kirschner ezingu-2-3 kungasetshenziswa. Ngokuphathelene nendlela yokusebenzisa, umbhali uncoma i-PCR (flexor carpi radialis) ukuze kwandiswe indlela ye-volar.
a, Ukufakwa kwesikhashana ngezintambo ezimbili zeKirschner, qaphela ukuthi ukuthambekela kwe-volar kanye nobuso be-articular akukabuyiselwa ngokuphelele ngalesi sikhathi;
b, Ucingo lweKirschner lulungisa ipuleti okwesikhashana, naka ukuqina kokuphela okukude kwerediyasi ngalesi sikhathi (indlela yokulungisa izingcezu zokuphuka okukude), ingxenye eseduze yepuleti idonswa iye ku-radial shaft ukuze kubuyiselwe ukuthambekela kwe-volar.
C, Ubuso be-articular bulungiswa kahle ngaphansi kwe-arthroscopy, kufakwa isikulufu/iphini lokukhiya elikude, bese kuthi i-proximal radius ekugcineni incishiswe futhi ilungiswe.
Amaphuzu ayisihluthuleloIndlela yokusondela: Ukusikwa kwesikhumba okude kuqala esikhumbeni esigoqekayo, futhi ubude baso bunganqunywa ngokuya ngohlobo lokuphuka. I-flexor carpi radialis tendon kanye nesigxobo sayo kuhlukaniswa kude kuya ethanjeni le-carpal futhi kube eduze ngangokunokwenzeka. Ukudonsa i-flexor carpi radialis tendon ohlangothini lwe-ulnar kuvikela i-median nerve complex kanye ne-flexor tendon complex. Isikhala seParona siyabonakala, lapho i-pronator quadratus itholakala phakathi kwe-flexor hallucis longus (ulnar) kanye ne-radial artery (radial). Ukusikwa kwenziwa ohlangothini lwe-radial lwe-pronator quadratus, kwashiya ingxenye inamathele ku-radius ukuze yakhiwe kabusha kamuva. Ukudonsa i-pronator quadratus ohlangothini lwe-ulnar kuveza ngokugcwele i-volar ulnar angle ye-radius.
Ngezinhlobo zokuphuka okuyinkimbinkimbi, kunconywa ukuthi kukhululwe ukufakwa okukude kwemisipha ye-brachioradialis, okunganciphisa ukudonsa kwayo enqubweni ye-radial styloid. Ngalesi sikhathi, i-volar sheath yegumbi lokuqala le-dorsal ingasikwa ukuze kuvele ukuphuka okukude. Vimba uhlangothi lwe-radial kanye nenqubo ye-radial styloid, ujikeleze ngaphakathi i-radial shaft ukuze ihlukane nendawo yokuphuka, bese usebenzisa izintambo ze-Kirschner ukunciphisa i-intra-articular fracture block. Ngeziqhekeko eziyinkimbinkimbi ze-intra-articular, i-arthroscopy ingasetshenziswa ukusiza ukunciphisa, ukuhlola, kanye nokulungisa kahle izingcezu zokuphuka.
Ngemva kokuqedwa kokunciphisa, ipuleti le-volar libekwa njalo. Ipuleti kumele libe seduze nje ne-watershed, kumele limboze inqubo ye-ulnar, futhi ukuphela kwepuleti kufanele kufinyelele phakathi nendawo ye-radial shaft. Uma izimo ezingenhla zingahlangatshezwanga, usayizi wepuleti awufaneleki, noma ukunciphisa kunganeliseki, ukusebenza akukapheleli.
Izinkinga eziningi zihlobene kakhulu nendawo ipuleti elibekwe kuyoUma ipuleti libekwe kakhulu, izinkinga ezihlobene ne-flexor hallucis longus zingenzeka; uma ipuleti libekwe eduze kakhulu nomugqa wamanzi, i-flexor digitorum profundus ingaba sengozini. Ukuncipha kokuphuka kokukhubazeka kwe-volar displacement deform kungabangela kalula ukuthi ipuleti lensimbi liphumele ohlangothini lwe-volar futhi lithinte ngqo i-flexor tendon, ekugcineni kuholele ku-tendinitis noma ngisho nokuqhekeka.
Kubantu abane-osteoporosis, kunconywa ukuthi ipuleti libe seduze nomugqa wamanzi ngangokunokwenzeka, kodwa kungabi ngaphesheya kwawo.Izintambo zeKirschner zingasetshenziswa ukulungisa i-subchondral eseduze ne-ulna, kanti izintambo zeKirschner eziseceleni kanye nezipikili nezikulufo ezikhiyayo zingavimbela ngempumelelo ukuqhekeka ekuphindeni kususwe.
Ngemva kokuba ipuleti libekwe kahle, ukuphela kwe-proximal kuyaqiniswa ngesikulufu, bese imbobo ye-ulnar ekugcineni kwepuleti iqiniswa okwesikhashana ngentambo ye-Kirschner. Umbono we-fluoroscopy we-Intraoperative anteroposterior, umbono we-lateral, ukuphakama kwe-wrist joint umbono we-lateral ongu-30°, ukunquma ukunciphisa ukuphuka kanye nesimo sokuqina kwangaphakathi. Uma indawo yepuleti iyanelisa, kodwa intambo ye-Kirschner isejoyintini, kuzoholela ekubuyiselweni okunganele kwe-volar inclination, okungaxazululwa ngokusetha kabusha ipuleti "ngendlela yokulungisa ukuphuka kwe-distal" (Isithombe 2, b).
Uma kuhambisana nokuqhekeka komgogodla kanye nomgogodla (i-ulnar/dorsal Die Punch) futhi kungenakuncishiswa ngokuphelele lapho kuvalwa, lezi zindlela ezintathu ezilandelayo zingasetshenziswa:
1. Veza ingxenye eseduze yerediyasi ukuze uyigcine kude nendawo yokuqhekeka, bese usunduza ukuqhekeka kwe-lunate fossa uye ku-carpus ngendlela yokwelulwa kwe-PCR;
2. Yenza imbobo encane ohlangothini lwangemuva lwegumbi lesi-4 nelesi-5 ukuze uveze ingxenye ephukile, bese uyilungisa ngezikulufo emgodini ongaphezulu kakhulu kwepuleti.
3. Ukufakwa kwe-percutaneous okuvaliwe noma okungangeni kakhulu ngosizo lwe-arthroscopy.
Ngemva kokuba ukunciphisa sekwanele futhi ipuleti libekwe kahle, ukulungiswa kokugcina kulula kakhulu. Uma ucingo lwe-proximal ulnar Kirschner lubekwe kahle futhi kungekho zikulufo eziku-joint cavity, kungatholakala ukunciphisa kwe-anatomical.
Ulwazi lokukhetha izikulufo: Ngenxa yokuphazamiseka okukhulu kwethambo le-dorsal cortical, ubude besikulufu kungaba nzima ukubulinganisa ngokunembile. Izikulufu ezinde kakhulu zingabangela ukucasuka kwe-tendon, kanti izikulufu ezimfushane kakhulu azikwazi ukusekela nokulungisa ingxenye ye-dorsal. Ngenxa yalesi sizathu, umbhali uncoma ukusebenzisa izikulufu zokukhiya ezinezintambo kanye nezikulufu zokukhiya ezine-multiaxial enqubweni ye-radial styloid kanye nembobo ye-ulnar kakhulu, kanye nokusebenzisa izikulufu zokukhiya zenduku ezipholishiwe kwezinye izikhundla. Ukusebenzisa ithiphu elibuthuntu kugwema ukucasuka kwe-tendon noma ngabe kusetshenziswa indlela yokuphuma ye-dorsal. Ukuze kufakwe ipuleti le-proximal interlocking, izikulufu ezimbili ezixhumene + isikulufu esisodwa esijwayelekile (esibekwe nge-ellipse) zingasetshenziswa ukuze kufakwe.
4. Isifinyezo sombhalo ogcwele:
Ukufakwa kwe-volar locking nail plate yokwaphuka kwe-distal radius kungafeza ukusebenza kahle kwezokwelapha, okuncike kakhulu ekukhetheni izinkomba kanye namakhono amahle kakhulu okuhlinzwa. Ukusebenzisa le ndlela kungenza kube ngcono ukubikezela kokusebenza kwasekuqaleni, kodwa akukho mehluko ekusebenzeni kamuva kanye nokusebenza kwezithombe ngezinye izindlela, ukwanda kwezinkinga zangemva kokuhlinzwa kuyafana, futhi ukwehla kuyalahleka ekufakweni kwangaphandle, ukufakwa kwentambo ye-percutaneous Kirschner, kanye nokufakwa kwe-plaster, ukutheleleka kwe-needle tract kuvame kakhulu; kanti izinkinga ze-extensor tendon zivame kakhulu ezinhlelweni zokufakwa kwe-distal radius plate. Kubantu abane-osteoporosis, i-volar plate iseyisinqumo sokuqala.
Isikhathi sokuthunyelwe: Disemba 12-2022
