Okwangoku, kukho iindlela ezahlukeneyo zonyango zokuqhekeka kwe-distal radius, ezifana nokufakelwa kwe-plaster, ukunciphisa okuvulekileyo kunye nokufakelwa kwangaphakathi, ifreyimu yokufakelwa kwangaphandle, njl. Phakathi kwazo, ukufakelwa kwe-volar plate kunokufumana isiphumo esanelisayo ngakumbi, kodwa kukho iingxelo kwiincwadi zokuba iingxaki zayo ziphezulu ukuya kwi-16%. Nangona kunjalo, ukuba ipleyiti yentsimbi ikhethwe ngokufanelekileyo, ukwenzeka kweengxaki kunokunciphisa ngempumelelo. Eli phepha lishwankathela ngokufutshane iimpawu, izalathiso, izithintelo, kunye neendlela zotyando zonyango lwe-volar plate kwii-distal radius fractures.
1. Kukho iingenelo ezimbini eziphambili zepleyiti esecaleni yesundu
A.Inganciphisa icandelo lamandla okugoba. Ukuqinisa ngezikrufu zokuqinisa ezijijekileyo kuxhasa iqhekeza elikude kwaye kudlulisele umthwalo kwi-radial shaft (Umzobo 1). Inokufumana inkxaso ye-subchondral ngempumelelo ngakumbi. Le nkqubo yeplate ayinakulungisa kuphela ngokuzinzileyo ukwaphuka kwe-distal intra-articular, kodwa ikwabuyisela ngokufanelekileyo isakhiwo se-anatomical sethambo le-intra-articular subchondral ngokusebenzisa ukuqina kwe-peg/screw "emilo yefeni". Kwiintlobo ezininzi zokwaphuka kwe-distal radius, le nkqubo yophahla inika uzinzo olongezelelekileyo oluvumela ukuhanjiswa kwangoko.
Umfanekiso 1, a, emva kokwakhiwa ngokutsha kwesaphuli esiqhelekileyo se-distal radius esaphukileyo, qwalasela inqanaba lokucinezelwa kwe-dorsal; b, ukunciphisa okubonakalayo kwesaphuli, isiphene kufuneka silungiswe kwaye sixhaswe yipleyiti; c, umbono osecaleni emva kokulungiswa kwe-DVR, utolo lubonisa ukudluliselwa komthwalo.
B. Impembelelo encinci kwizicubu ezithambileyo: ukufakwa kweplati ye-volar kungaphantsi kancinci komgca we-watershed, xa kuthelekiswa neplati ye-dorsal, kunokunciphisa ukurhawuzelelwa kwi-tendon, kwaye kukho indawo engakumbi ekhoyo, enokuthi iphephe ukudibana ngqo ne-implant kunye ne-tendon ngempumelelo. Ukongeza, uninzi lwe-implants lunokugqunywa yi-pronator quadratus.
2. Iimpawu kunye nokuchasene nokunyanga i-distal radius nge-volar plate
a.Iimpawu: Xa ukusilela kokunciphisa okuvaliweyo kokuqhekeka kwe-extra-articular, ezi meko zilandelayo ziyavela, ezifana ne-dorsal angulation engaphezulu kwama-20°, ucinezelo lwe-dorsal olungaphezulu kwama-5mm, ukufinyela kwe-distal radius engaphezulu kwama-3mm, kunye nokufuduka kwe-distal fracture fragment engaphezulu kwama-2mm; Ukufuduka kwe-internal fracture kungaphezulu kwama-2 mm; ngenxa yoxinano oluphantsi lwamathambo, kulula ukubangela ukufuduka kwakhona, ngoko ke kufanelekile ngakumbi kubantu abadala.
b. Izithintelo: ukusetyenziswa kwe-anesthetics yendawo, izifo ezisulelayo zasekuhlaleni okanye zenkqubo yomzimba, imeko embi yolusu kwicala le-volar lesandla; ubunzima bethambo kunye nohlobo lokuqhekeka kwindawo yokuqhekeka, uhlobo lokuqhekeka komqolo olufana nokuqhekeka kukaBarton, ukwaphuka kunye nokudilika kwamalungu e-radiocarpal, i-simple radius Ukuqhekeka kwenkqubo ye-Styloid, ukwaphuka okuncinci kwe-avulsion kwi-volar margin.
Kwizigulana ezineengozi ezinamandla aphezulu ezifana nokuqhekeka okukhulu kwe-intra-articular comminuted okanye ukulahleka kwamathambo okukhulu, uninzi lweengcali alucebisi ukusetyenziswa kwee-volar plates, kuba ezo fractures ze-distal zisengozini ye-vascular necrosis kwaye kunzima ukufumana ukunciphisa i-anatomical. Kwizigulana ezinee-fractures ezininzi kunye nokufuduka okukhulu kunye ne-osteoporosis enzima, i-volar plate kunzima ukuyisebenzisa. Kunokubakho iingxaki ngenkxaso ye-subchondral kwi-distal fractures, njengokungena kwe-screw kwi-joint cavity. Uncwadi lwakutshanje lubike ukuba xa amatyala angama-42 e-intra-articular fractures enyangwa ngee-volar plates, akukho zi-articular screws zingene kwi-articular cavity, eyayinxulumene kakhulu nendawo yee-plates.
3. Izakhono zotyando
Uninzi loogqirha basebenzisa i-volar plate fixation kwii-distal radius fractures ngeendlela ezifanayo kunye neendlela. Nangona kunjalo, ukuze kuthintelwe ngempumelelo ukwenzeka kweengxaki emva kotyando, kufuneka indlela entle yotyando, umzekelo, ukunciphisa kunokufumaneka ngokukhulula uxinzelelo lwe-fracture block kunye nokubuyisela ukuqhubeka kwethambo le-cortical. I-fixation yexeshana ngee-2-3 Kirschner wires zingasetyenziswa. Ngokuphathelele indlela yokusebenzisa, umbhali ucebisa i-PCR (flexor carpi radialis) ukwandisa indlela ye-volar.
a, Ukulungiswa okwethutyana ngeentambo ezimbini zeKirschner, qaphela ukuba ukuthambekela kwe-volar kunye nomphezulu we-articular azikabuyiselwa ngokupheleleyo ngeli xesha;
b, Ucingo lweKirschner lulungisa ipleyiti okwethutyana, nikela ingqalelo ekulungisweni kwesiphelo esikude seradius ngeli xesha (indlela yokulungisa iziqwenga zokuqhekeka kwe-distal), inxalenye ekufutshane yepleyiti itsalwa iye kwi-radial shaft ukuze kubuyiselwe ukuthambekela kwe-volar.
C, Umphezulu we-articular ulungiswa kakuhle phantsi kwe-arthroscopy, kubekwa isikrufu/iphini yokutshixa ekude, kwaye i-proximal radius ekugqibeleni incitshisiwe kwaye ilungisiwe.
Amanqaku aphambiliindlela yokusondela: Ukusikwa kwesikhumba okukude kuqala kwisingxobo sesikhumba sesandla, kwaye ubude baso bunokuqinisekiswa ngokohlobo lokuqhekeka. I-tendon ye-flexor carpi radialis kunye ne-sheath yayo zinqunyulwe ukusuka kude ukuya kwithambo le-carpal kwaye zisondele kangangoko kunokwenzeka. Ukutsala i-tendon ye-flexor carpi radialis ukuya kwicala le-ulnar kukhusela i-median nerve kunye ne-flexor tendon complex. Indawo yeParona iveziwe, kunye ne-pronator quadratus ebekwe phakathi kwe-flexor hallucis longus (ulnar) kunye ne-radial artery (radial). Ukusikwa kwenziwe kwicala le-radial le-pronator quadratus, kushiyeka inxalenye inamathele kwi-radius ukuze yakhiwe kwakhona kamva. Ukutsala i-pronator quadratus kwicala le-ulnar kuveza ngokupheleleyo i-volar ulnar angle ye-radius.
Kwiintlobo zokwaphuka ezintsonkothileyo, kuyacetyiswa ukuba kukhululwe ukufakwa kwemisipha ye-brachioradialis, enokuthi ithintele ukutsala kwayo kwinkqubo ye-radial styloid. Ngeli xesha, i-volar sheath yecandelo lokuqala le-dorsal ingasikwa ukuze kubonakale ukwaphuka kwe-distal. Vimba icala le-radial kunye nenkqubo ye-radial styloid, ujikeleze ngaphakathi i-radial shaft ukuze yahluke kwindawo yokwaphuka, uze usebenzise iingcingo zeKirschner ukunciphisa ibhloko yokwaphuka kwe-intra-articular. Kwii-complex intra-articular fractures, i-arthroscopy ingasetyenziselwa ukunceda ukunciphisa, ukuvavanya, kunye nokulungisa kakuhle iziqwenga zokwaphuka.
Emva kokuba ukuncipha kugqityiwe, ipleyiti yevolar ibekwa rhoqo. Ipleyiti kufuneka ibe kufutshane nje ne-watershed, igqume inkqubo ye-ulnar, kwaye isiphelo esikufutshane sepleyiti kufuneka sifikelele kumbindi we-radial shaft. Ukuba ezi meko zingasentla azifezekiswanga, ubungakanani bepleyiti abufanelekanga, okanye ukuncipha akwanelisi, umsebenzi awukagqibeleli.
Iingxaki ezininzi zinxulumene kakhulu nendawo ebekwe kuyo ipleyitiUkuba ipleyiti ibekwe kakhulu, iingxaki ezinxulumene ne-flexor hallucis longus zinokwenzeka; ukuba ipleyiti ibekwe kufutshane kakhulu nomgca wamanzi, i-flexor digitorum profundus inokuba semngciphekweni. Ukuncipha kokuqhekeka ngenxa yokukhubazeka kwe-volar displacement deformity kunokubangela ukuba ipleyiti yentsimbi ivele kwicala le-volar kwaye iqhagamshelane ngqo ne-flexor tendon, ekugqibeleni ikhokelele kwi-tendinitis okanye ukuqhekeka.
Kwabo bane-osteoporosis, kucetyiswa ukuba ipleyiti isondele kakhulu kumgca wamanzi ngangokunokwenzeka, kodwa ingabi ngaphaya kwawo.Iintambo zeKirschner zingasetyenziselwa ukulungisa i-subchondral ekufutshane ne-ulna, kwaye iintambo zeKirschner ezikufutshane kunye nezikhonkwane ezitshixayo kunye nezikrufu zinokuthintela ngempumelelo ukwaphuka ukuba kungaphindi kufuduke.
Emva kokuba ipleyiti ibekwe ngokuchanekileyo, isiphelo esikufutshane siyaqiniswa ngesikrufu, kwaye umngxuma we-ulnar kwisiphelo esikude sepleyiti uqiniswa okwethutyana ngentambo yeKirschner. I-Intraoperative fluoroscopy anteroposterior view, side view, wrist joint elevation 30° lateral view, ukumisela ukunciphisa ukwaphuka kunye nendawo yokuqina kwangaphakathi. Ukuba indawo yepleyiti iyanelisa, kodwa intambo yeKirschner ikwijoyinti, kuya kukhokelela ekubuyiselweni okwaneleyo kwe-volar inclination, enokusonjululwa ngokuseta kwakhona ipleyiti "ngendlela yokulungisa ukwaphuka kwe-distal" (Umzobo 2, b).
Ukuba ihamba kunye nokuqhekeka kwamathambo emqolo kunye ne-ulnar (ulnar/dorsal Die Punch) kwaye ayinakuncitshiswa ngokupheleleyo xa ivaliwe, ezi ndlela zintathu zilandelayo zingasetyenziswa:
1. Phakamisa isiphelo esikufutshane seradius ukuze usigcine kude nendawo yokuqhekeka, uze utyhale ukuqhekeka kwe-lunate fossa uye kwi-carpus ngendlela yokwandisa i-PCR;
2. Yenza umngxuma omncinci kwicala langasemva legumbi lesi-4 nelesi-5 ukuze uveze iqhekeza elaphukileyo, uze ulilungise ngezikrufu kumngxuma ongaphezulu kwepleyiti.
3. Ukufakelwa okuvaliweyo kwe-percutaneous okanye okuncinci ngoncedo lwe-arthroscopy.
Emva kokuba ukunciphisa kube kwanele kwaye ipleyiti ibekwe ngokuchanekileyo, ukulungiswa kokugqibela kulula. Ukuba ucingo lwe-proximal ulnar Kirschner lubekwe ngokuchanekileyo kwaye akukho zikrufu zikwi-joint cavity, ukunciphisa kwe-anatomical kungafunyanwa.
Amava okukhetha izikrufu: Ngenxa yokuphazamiseka okukhulu kwethambo le-dorsal cortical, ubude besikrufu bunokuba nzima ukubulinganisa ngokuchanekileyo. Izikrufu ezinde kakhulu zinokubangela ukurhawuzelelwa kwe-tendon, kwaye izikrufu ezimfutshane kakhulu azikwazi ukuxhasa nokulungisa iqhekeza le-dorsal. Ngenxa yesi sizathu, umbhali ucebisa ukusebenzisa izikrufu zokukhiya ezinemisonto kunye nezikrufu zokukhiya ezine-multiaxial kwinkqubo ye-radial styloid kunye nomngxuma we-ulnar kakhulu, kunye nokusebenzisa izikrufu zokukhiya zentonga epholishiweyo kwezinye iindawo. Ukusebenzisa i-blunt tip kuthintela ukurhawuzelelwa kwe-tendon nokuba kusetyenziswa indlela yokuphuma kwe-dorsal. Kwi-proximal interlocking plate fixation, izikrufu ezimbini ezinxityelelanisiweyo kunye nesikrufu esinye esiqhelekileyo (esibekwe kwi-ellipse) zingasetyenziselwa ukuqiniswa.
4. Isishwankathelo sesicatshulwa esipheleleyo:
Ukulungiswa kwepleyiti yezipikili ezitshixwayo ze-distal radius fractures kunokufezekisa ukusebenza kakuhle kwezonyango, okuxhomekeke kakhulu ekukhetheni izalathiso kunye nezakhono zotyando ezibalaseleyo. Ukusebenzisa le ndlela kunokufumana i-prognosis engcono yokusebenza kwangethuba, kodwa akukho mahluko ekusebenzeni kamva kunye nokusebenza kwemifanekiso ngezinye iindlela, ukwenzeka kweengxaki emva kotyando kuyafana, kwaye ukuncipha kuyalahleka kwi-external fixation, percutaneous Kirschner wire fixation, kunye ne-plaster fixation, usulelo lwe-needle tract luxhaphake kakhulu; kwaye iingxaki ze-extensor tendon zixhaphake kakhulu kwiinkqubo ze-distal radius fixation plate. Kwizigulane ezine-osteoporosis, i-volar plate iselukhetho lokuqala.
Ixesha lokuthumela: Disemba-12-2022
