Njengamanje, kunezindlela ezihlukahlukene zokwelashwa kwe-distal radius fractures, njengokulungiswa kwe-plaster, ukunciphisa okuvulekile nokulungiswa kwangaphakathi, uhlaka lokulungiswa kwangaphandle, njll. Phakathi kwabo, ukulungiswa kwepuleti ye-volar kungathola umphumela owanelisayo, kodwa kunemibiko ezincwadini. ukuthi izinkinga zayo ziphezulu njenge-16%.Kodwa-ke, uma ipuleti yensimbi ikhethwe kahle, izehlakalo zezinkinga zingancishiswa ngokuphumelelayo.Leli phepha lifingqa kafushane izici, izinkomba, ukungqubuzana, nezindlela zokuhlinza zokwelashwa kwepuleti le-volar lokuqhekeka kwe-distal radius.
1. Kukhona izinzuzo ezimbili eziyinhloko ze-palm side plate
A.Inganciphisa ingxenye yamandla okubopha.Ukulungiswa ngezikulufu zokulungisa ama-angled kusekela isiqeshana se-distal futhi sidlulisela umthwalo ku-shaft ye-radial (Fig. 1).Ingathola ukwesekwa kwe-subchondral ngempumelelo kakhulu.Lolu hlelo lwepuleti alukwazi nje ukulungisa ngokuzinza ukuphuka kwe-distal intra-articular, kodwa futhi lungabuyisela ngempumelelo ukwakheka kwe-anatomical ye-intra-articular subchondral bone ngokusebenzisa isikhonkwane/isikulufa "okumise okwefeni".Ezinhlotsheni eziningi zokuqhekeka kwerediyasi ekude, le sistimu yophahla inikeza ukuzinza okwengeziwe okuvumela ukuhlanganisa kusenesikhathi.
Isithombe 1, a, ngemva kokwakhiwa kabusha okunezinhlangothi ezintathu kokuhlukana okujwayelekile kwe-distal radius comminuted, qaphela izinga lokucindezelwa komgogodla;b, ukuncishiswa okubonakalayo kokuphuka, ukukhubazeka kufanele kulungiswe futhi kusekelwe ipuleti;c, ukubuka kwezinhlangothi ngemva kokulungiswa kwe-DVR, umcibisholo ubonisa ukudluliswa komthwalo .
B. Umthelela ongaphansi kwezicubu ezithambile: ukulungiswa kwepuleti ye-volar kungaphansi kancane komugqa wamanzi, uma kuqhathaniswa ne-dorsal plate, kunganciphisa ukucasuka ku-tendon, futhi kunesikhala esitholakalayo, esingagwema ngokuphumelelayo ukufakelwa kanye ne-tendon.ukuthintana ngqo.Ukwengeza, izimila eziningi zingambozwa yi-pronator quadratus.
2. Izinkomba kanye contraindications ekwelapheni engaba distal nge plate volar
Izinkomba: Ngokuhluleka kokunciphisa ukuvala ukuphuka kwe-extra-articular fractures, izimo ezilandelayo zenzeka, ezifana ne-dorsal angulation enkulu kuno-20 °, ukucindezelwa komgogodla okukhulu kuno-5mm, ukufinyezwa kwe-distal radius enkulu kuno-3mm, kanye nokususwa kwe-distal fragment enkulu kuno-5mm. 2mm;Ukususwa kwe-fracture yangaphakathi kukhulu kune-2 mm;ngenxa yokuncipha kwamathambo, kulula ukubangela ukufuduka kabusha, ngakho-ke kufaneleka kakhulu kubantu asebekhulile.
b.Ukuphikisana: ukusetshenziswa kwezidakamizwa zendawo, izifo ezithathelwanayo zendawo noma zesistimu, isimo esibi sesikhumba ohlangothini lwe-volar yesihlakala;ubukhulu bethambo kanye nohlobo lokuphuka endaweni yokuphuka, uhlobo lwe-dorsal fracture efana ne-Barton fracture, i-radiocarpal joint fracture kanye ne-dislocation, i-radius elula ye-Styloid inqubo yokuphuka, ukuphuka okuncane kwe-avulsion ye-volar margin.
Ezigulini ezinokulimala okunamandla okunamandla okufana nokuqhekeka okukhulu kwe-intra-articular comminuted noma ukulahlekelwa okukhulu kwamathambo, izazi eziningi azikukhuthazi ukusetshenziswa kwamapuleti e-volar, ngoba ukuhlukana okunjalo kwe-distal kujwayele ukuba necrosis ye-vascular futhi kunzima ukuthola ukunciphisa kwe-anatomical.Ezigulini ezinezicucu eziningi zokuphuka kanye nokufuduka okuphawulekayo kanye ne-osteoporosis enzima, i-volar plate inzima ukusebenza kahle.Kungase kube nezinkinga ngokusekelwa kwe-subchondral ekuqhekekeni kwe-distal, njengokungena kwesikulufa emgodini ohlangene.Izincwadi zamuva zibike ukuthi lapho amacala angu-42 e-intra-articular fractures ephathwa ngamapuleti e-volar, azikho izikulufo ze-articular ezangena emgodini we-articular, owawuhlobene ngokuyinhloko nokuma kwamapuleti.
3. Amakhono okuhlinza
Odokotela abaningi basebenzisa i-volar plate fixation ye-distal radius fractures ngezindlela nezindlela ezifanayo.Kodwa-ke, ukuze ugweme ngokuphumelelayo ukuvela kwezinkinga zangemva kokuhlinzwa, inqubo yokuhlinzwa ephakeme kakhulu iyadingeka, isibonelo, ukunciphisa kungatholakala ngokukhulula ukucindezelwa kwe-block fracture nokubuyisela ukuqhubeka kwethambo le-cortical.Ukulungiswa kwesikhashana ngezintambo ze-2-3 Kirschner kungasetshenziswa.Ngokuphathelene nokuthi iyiphi indlela okufanele isetshenziswe, umbhali uncoma i-PCR (flexor carpi radialis) ukunweba indlela ye-volar.
a, Ukulungiswa Kwesikhashana ngezintambo ezimbili ze-Kirschner, qaphela ukuthi ukuthambekela kwe-volar kanye ne-articular surface akubuyiselwe ngokugcwele ngalesi sikhathi;
b, Intambo ye-Kirschner ilungisa ipuleti okwesikhashana, qaphela ukumiswa kwe-distal end yerediyasi ngalesi sikhathi (isu lokulungisa i-distal fragment fragment), ingxenye eseduze yepuleti idonselwa ku-shaft ye-radial ukubuyisela ukuthambekela kwe-volar. .
C, I-articular surface icushwe kahle ngaphansi kwe-arthroscopy, isikulufa/iphinikhodi yokukhiya i-distal ibekwe, futhi i-proximal radius ekugcineni incishisiwe futhi ilungisiwe.
Amaphuzu abalulekileindlela yokusondela: Ukusika kwesikhumba esikude kuqala esikhumbeni sesihlakala, futhi ubude baso bunganqunywa ngokohlobo lokuphuka.Ithenda ye-flexor carpi radialis kanye ne-sheath yayo ihlukaniswa kude nethambo le-carpal futhi isondele ngangokunokwenzeka.Ukudonsa i-flexor carpi radialis tendon ohlangothini lwe-ulnar kuvikela i-nerve median kanye ne-flexor tendon complex.Isikhala se-Parona sisobala, ne-pronator quadratus etholakala phakathi kwe-flexor hallucis longus (ulnar) kanye nomthambo we-radial (radial).Ukusika kwenziwa ohlangothini lwe-radial lwe-quadratus ye-pronator, kushiya ingxenye enamathiselwe endaweni ukuze yakhiwe kabusha kamuva.Ukudonsa i-pronator quadratus ohlangothini lwe-ulnar kuveza ngokugcwele i-engeli ye-volar ulnar yerediyasi.
Ngezinhlobo eziyinkimbinkimbi zokuphuka, kunconywa ukukhulula ukufakwa kwe-distal kwemisipha ye-brachioradialis, enganciphisa ukudonsa kwayo kwinqubo ye-styloid ye-radial.Ngalesi sikhathi, i-volar sheath yendawo yokuqala yomgogodla ingasikwa ukuze kuvezwe ukuphuka kwe-distal Vimba uhlangothi lwe-radial kanye nenqubo ye-styloid ye-radial, ujikeleze ngaphakathi kwe-shaft ye-radial ukuze uhlukane nesayithi lokuphuka, bese usebenzisa izintambo ze-Kirschner ukunciphisa i-intra. - i-articular fracture block.Ngokuhlukana okuyinkimbinkimbi kwe-intra-articular, i-arthroscopy ingasetshenziswa ukusiza ukunciphisa, ukuhlola, nokulungiswa kahle kwezingcezu zokuphuka.
Ngemuva kokuqedwa kokunciphisa, ipuleti ye-volar ibekwa njalo.Ipuleti kufanele libe eduze nje nendawo yamanzi, kufanele limboze inqubo ye-ulnar, futhi ukuphela okuseduze kwepuleti kufanele kufinyelele phakathi nendawo ye-radial shaft.Uma lezi zimo ezingenhla zingafinyelelwanga, usayizi wepuleti awufanelekile, noma ukunciphisa akugculisi, ukusebenza namanje akuphelele.
Izinkinga eziningi zihlobene kakhulu nalapho ipuleti libekwe khona.Uma ipuleti ibekwe kakhulu, izinkinga ezihlobene ne-flexor hallucis longus zihlelwe ngaphambili;uma ipuleti ibekwe eduze kakhulu nomugqa wamanzi, i-flexor digitorum profundus ingase ibe engozini.Ukwehliswa kokuphuka kokukhubazeka kwe-volar displacement kungase kubangele kalula ipuleti lensimbi ukuba liphumele ohlangothini lwe-volar futhi lithinte ngokuqondile i-flexor tendon, ekugcineni kuholele ku-tendinitis noma ngisho nokuphuka.
Ezigulini ezine-osteoporotic, kunconywa ukuthi ipuleti libe seduze nomugqa wamanzi ngangokunokwenzeka, kodwa hhayi ngaphesheya kwalo..Izintambo ze-Kirschner zingasetshenziswa ukulungisa i-subchondral eseduze kakhulu ne-ulna, futhi izintambo ze-Kirschner ezihlangothini ne-side nezipikili zokukhiya nezikulufi zingavimbela ngempumelelo ukuphuka ekususweni kabusha.
Ngemuva kokuthi ipuleti libekwe kahle, isiphetho esiseduze silungiswa ngesikulufu, futhi imbobo ye-ulnar ekugcineni ekude yepuleti ilungiswa okwesikhashana ngentambo ye-Kirschner.Ukubuka kwe-intraoperative fluoroscopy anteroposterior, ukubukwa kwe-lateral, ukuphakama kwe-wrist joint 30 ° ukubuka kwe-lateral, ukuze kunqunywe ukunciphisa ukuphuka kanye nesimo sangaphakathi sokulungisa.Uma isikhundla sepuleti sigculisayo, kodwa ucingo lwe-Kirschner luhlangene, luzoholela ekubuyiseleni okunganele kokuthambekela kwe-volar, okungaxazululwa ngokusetha kabusha ipuleti ngokusebenzisa "inqubo yokulungisa i-distal fracture" (Fig. 2). b).
Uma ihambisana nokuphuka komgogodla kanye ne-ulnar (i-ulnar/dorsal Die Punch) futhi ayikwazi ukuncishiswa ngokugcwele ngaphansi kokuvalwa, izindlela ezintathu ezilandelayo zingasetshenziswa:
1. Zungeza isiphetho esiseduze serediyasi ukuyigcina ikude nendawo yokuphuka, bese uphushela ukuphuka kwe-fossa kwenyanga ukuya ku-carpus ngokusebenzisa indlela yokunweba ye-PCR;
2. Yenza ukusika okuncane ohlangothini lwedorsal lwekhompathimenti yesi-4 neyesi-5 ukuze uveze ucezu oluphukile, futhi usilungise ngezikulufu emgodini omkhulu we-ulnar wepuleti.
3. Ukulungiswa kwe-percutaneous okuvaliwe noma okuncane kakhulu ngosizo lwe-arthroscopy.
Ngemuva kokunciphisa kuyanelisa futhi ipuleti ibekwe ngendlela efanele, ukulungiswa kokugcina kulula.Uma i-proximal ulnar wire Kirschner imiswe kahle futhi zingekho izikulufu endaweni ehlangene, ukuncishiswa kwe-anatomical kungatholwa.
Umuzwa wokukhetha isikulufu: Ngenxa yokuqina okuqinile kwethambo le-cortical dorsal, ubude besikulufu bungase bube nzima ukubulinganisa ngokunembile.Izikulufu ezinde kakhulu zingase zibangele ukucasuka kwethenda, futhi izikulufu ezimfishane kakhulu azikwazi ukusekela futhi zilungise ucezwana lomhlane.Ngalesi sizathu, umbhali uncoma ukuthi kusetshenziswe izikulufu zokukhiya ezinentambo nezikulufu zokukhiya ze-multiaxial kunqubo ye-radial styloid kanye nembobo enkulu ye-ulnar, kanye nokusebenzisa izikulufu zokukhiya induku epholishiwe kuzo zonke ezinye izindawo.Ukusebenzisa ithiphu elibuthuntu kugwema ukucasuka kwethenda ngisho noma kusetshenziswa indlela yokuphuma emhlane.Ukuze kulungiswe ipuleti elixhumene eliseduze, izikulufu ezimbili ezihilelekile + isikulufu esisodwa esijwayelekile (esibekwe ku-ellipse) singasetshenziselwa ukulungiswa.
4. Isifinyezo sombhalo ogcwele:
I-Volar locking nail plate fixation ye-distal radius fractures ingafinyelela ukusebenza kahle komtholampilo, okuncike kakhulu ekukhethweni kwezinkomba kanye namakhono amahle kakhulu okuhlinza.Ukusebenzisa le ndlela kungathola isibikezelo esingcono sokuqala sokusebenza, kodwa akukho mehluko ekusebenzeni kamuva nokusebenza kwe-imaging nezinye izindlela, izehlakalo zezinkinga zangemva kokuhlinzwa ziyafana, futhi ukuncishiswa kulahleka ekulungiseni kwangaphandle, ukulungiswa kwe-percutaneous Kirschner wire, kanye nokulungiswa kwe-plaster. , izifo zenaliti zivame kakhulu;futhi izinkinga ze-tendon ye-extensor zivame kakhulu ezinhlelweni zokulungisa i-distal radius plate.Ezigulini ezine-osteoporosis, ipuleti ye-volar iseyisinqumo sokuqala.
Isikhathi sokuthumela: Dec-12-2022
