夹板固定治疗尺骨茎突骨折的三维有限元分析
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摘要
背景:桡骨远端骨折常伴有尺骨茎突骨折,临床中对尺骨茎突骨折的治疗存在争议。手法复位夹板固定是治疗此类疾病的常用方法,治疗过程中对尺骨茎突骨折干预的机制难以在尸体力学实验中获得。近年来有限元分析方法在骨科领域得到了广泛应用,为骨科疾病的研究开辟了途径。目的:通过有限元分析方法,探讨夹板对尺骨茎突骨折干预的生物力学机制,为临床治疗选择提供理论依据。方法:基于1名健康女志愿者的前臂及腕部CT图像建立正常腕关节三维有限元基础模型,通过与文献中尸体实验数据对比验证模型的有效性,以此为基础建立有、无夹板固定的尺骨茎突Ⅰ型和Ⅱ型骨折的4种腕关节有限元模型。分析各模型在轴向压缩、横向拉伸、旋前和旋后4种工况下,下尺桡关节的相对位移变化、尺骨茎突骨折端位移变化情况。结果与结论:(1)建立并验证了正常腕关节的三维有限元模型,以此为基础建立出实验所需另外4种模型;(2)在旋前及旋后工况中,尺骨茎突Ⅰ型及Ⅱ型骨折模型下尺桡关节的相对位移值均大于正常腕关节模型,其中Ⅰ型骨折模型小于Ⅱ型骨折模型,夹板干预后2种骨折模型位移值均明显减小;(3)在横向拉伸、旋前及旋后工况中,尺骨茎突Ⅰ型模型尺骨茎突骨折端位移值小于Ⅱ型骨折模型,夹板干预后2种骨折模型位移值均明显减小。其余工况下以上相应数值相差不明显;(4)结果提示,尺骨茎突骨折后下尺桡关节稳定性变差,其中发生Ⅱ型骨折后下尺桡关节稳定性不及Ⅰ型骨折,夹板这一弹性固定方式在治疗周期中能够增加尺侧柱的稳定性。
BACKGROUND: Distal radius fractures are often accompanied by the ulna styloid process fractures, and the treatment of the ulna styloid process fracture is disputed in clinic. Manipulative reduction and splint fixation is a common method to treat such diseases. The mechanism of intervention on ulnar styloid process is difficult to obtain in the corpse mechanics experiments. In recent years, the finite element analysis method has been widely used in the field of orthopedics, which has opened up a way for the study of orthopedic disease. OBJECTIVE: To explore the biomechanical mechanism of splint intervention on ulnar styloid fracture by finite element analysis, and to provide the basis for clinical treatment choice. METHODS: A three-dimensional finite element model of normal wrist joint was established based on the forearm and wrist CT images of a healthy volunteer. The validity of the model was verified by comparing with the experimental data in the literature. On this basis, four wrist joint finite element models with and without splint fixation for ulnar styloid type I and type II fractures were established. Under axial compression, lateral extension, pronation and supination working conditions, the changes of the relative displacement of the distal radioulnar joint and the ulnar styloid fracture broken end were analyzed. RESULTS AND CONCLUSION:(1) A three-dimensional finite element model of normal wrist joint was established and validated, and the other four models were established based on this model.(2) In pronation and supination conditions, the relative displacement values of the ulnar and radial joints in the ulnar styloid type I and II fracture models were greater than those in the normal wrist joint model, and the displacement was smaller in the type I fracture model than in the type II fracture model; the displacement was significantly reduced after the intervention on the two fracture models by the splint.(3) In the lateral tension, pronation and supination conditions, the displacement values of the ulnar styloid fracture end in the ulnar styloid type I fracture model were smaller than in the type II fracture model, and the displacement values were significantly reduced after the intervention by the splint. Under the remaining conditions, the change of the above values was not obvious.(4) In conclusion, the stability of distal radioulnar joint became worse after ulnar styloid fracture, and the stability of distal radioulnar joint after type I fracture was less than that after type II fracture. As an elastic fixation method, splint can increase the stability of the wrist ulnar column during the treatment.
BACKGROUND: Distal radius fractures are often accompanied by the ulna styloid process fractures, and the treatment of the ulna styloid process fracture is disputed in clinic. Manipulative reduction and splint fixation is a common method to treat such diseases. The mechanism of intervention on ulnar styloid process is difficult to obtain in the corpse mechanics experiments. In recent years, the finite element analysis method has been widely used in the field of orthopedics, which has opened up a way for the study of orthopedic disease. OBJECTIVE: To explore the biomechanical mechanism of splint intervention on ulnar styloid fracture by finite element analysis, and to provide the basis for clinical treatment choice. METHODS: A three-dimensional finite element model of normal wrist joint was established based on the forearm and wrist CT images of a healthy volunteer. The validity of the model was verified by comparing with the experimental data in the literature. On this basis, four wrist joint finite element models with and without splint fixation for ulnar styloid type I and type II fractures were established. Under axial compression, lateral extension, pronation and supination working conditions, the changes of the relative displacement of the distal radioulnar joint and the ulnar styloid fracture broken end were analyzed. RESULTS AND CONCLUSION:(1) A three-dimensional finite element model of normal wrist joint was established and validated, and the other four models were established based on this model.(2) In pronation and supination conditions, the relative displacement values of the ulnar and radial joints in the ulnar styloid type I and II fracture models were greater than those in the normal wrist joint model, and the displacement was smaller in the type I fracture model than in the type II fracture model; the displacement was significantly reduced after the intervention on the two fracture models by the splint.(3) In the lateral tension, pronation and supination conditions, the displacement values of the ulnar styloid fracture end in the ulnar styloid type I fracture model were smaller than in the type II fracture model, and the displacement values were significantly reduced after the intervention by the splint. Under the remaining conditions, the change of the above values was not obvious.(4) In conclusion, the stability of distal radioulnar joint became worse after ulnar styloid fracture, and the stability of distal radioulnar joint after type I fracture was less than that after type II fracture. As an elastic fixation method, splint can increase the stability of the wrist ulnar column during the treatment.
引文
[1]May MM,Lawton JN,Blazar PE.Ulnar styloid fractures associated with distal radius fractures:incidence and implications for distal radioulnar joint instability.J Hand Surg Am.2002;27(6):965-971.
[2]Rikli DA,Regazzoni P.Fractures of the distal end of the radius treated by internal fixation and early function.A preliminary report of 20 cases.J Bone Joint Surg Br.1996;78(4):588-592.
[3]Henry MH.Management acute triangular fibrocartilage complex injury of the wrist.J Am Acad Orthop Surg.2008,16(6):320-329.
[4]Anderson ML,Larson AN,Moran SL,et al.Clinical comparison of arthroscopic versus open repair of triangular fibrocartilage complex tears.J Hand Surg Am.2008;33(5):675-682.
[5]Abe Y,Moriya A,Tominaga Y,et al.Dorsal tear of triangular fibrocartilage complex:clinical features and treatment.J Wrist Surg.2016;5(1):42-46.
[6]杨焕,王斌,李浩,等.尺骨茎突解剖特点与骨折分型及治疗方法[J].中国临床解剖学杂志,2012,30(5):564-567.
[7]Woo SJ,Jegal M,Park MJ.Arthroscopic-assisted repair of triangular fibrocartilage complex foveal avulsion in distal radioulnar joint injury.Indian J Orthop.2016;50(3):263-268.
[8]Moritomo H.The distal interosseous membrane:current concepts in wrist anatomy and biomechanics.J Hand Surg Am.2012;37(7):1501-1507.
[9]Zlatkin M B,Rosner J.MR imaging of ligaments and triangular fibrocartilage complex of the wrist.Radiol Clin North Am.2006;44(4):595-623.
[10]尚峥辉,黄富国,岑石强,等.三角纤维软骨复合体损伤后腕关节稳定性的生物力学分析[J].中国修复重建外科杂志,2008,22(7):820-823.
[11]张光辉.桡骨远端骨折合并的尺骨茎突骨折内固定与否对腕关节功能的影响[J].临床医药文献电子杂志,2016,3(41):8162-8164.
[12]Ayalon O,Marcano A,Paksima N,et al.Concomitant ulnar styloid fracture and distal radius fracture portend poorer outcome.Am J Orthop.2016;45(1):34-37.
[13]Yilmaz S,Cankaya D,Karakus D.Ulnar styloid fracture has no impact on the outcome but decreases supination strength after conservative treatment of distal radial fracture.2015;20(8):1497-1502.
[14]Kr?mer S,Meyer H,O'Loughlin P F,et al.The incidence of ulnocarpal complaints after distal radial fracture in relation to the fracture of the ulnar styloid.J Hand Surg Eur Vol.2013;38(7):710-717.
[15]Shirakawa K,Shirota M.T.A.C.Pin fixation for basal ulnar styloid fractures associated with distal radius fractures.Tech Hand Up Extrem Surg.2013;17(3):158-161.
[16]靳家骋,张坤鹏,黄富国.合并尺骨茎突骨折对桡骨远端骨折预后影响的Meta分析[J].中国循证医学杂志,2014,14(6):729-733.
[17]赵雪明,都晋江.前后石膏夹板固定治疗桡骨远端骨折68例疗效分析[J].临床医药实践,2009,18(9):719-720.
[18]Kang YK,Park HC,Youm Y,et al.Three dimensional shape reconstruction and finite element analysis of femur before and after the cementless type of total hip replacement.J Biomed Eng.1993;15:497-504.
[19]Lotz JC,Cheal EJ,Hayes WC.Fracture prediction for the proximal femur using finite element models:partl-linear analysis.J Biomech Engin.1991;11(2):353-360.
[20]徐永清,钟世镇,徐达传,等.腕关节韧带的解剖学研究[J].创伤外科杂志,2006,8(1):52-54.
[21]颜冰珊.尺骨茎突骨折与下尺桡关节稳定性关系的有限元分析[D].复旦大学,2009.
[22]郭欣,樊瑜波,李宗明.掌骨受轴向压力作用下的腕部生物力学分析[J].航天医学与医学工程,2008,21(1):45-49.
[23]Anderson DD,Daniel TE.A contact-coupled finite element analysis of the radiocarpal joint.Semin Arthroplasty.1995;6(1):30-36.
[24]周恩昌.塑形夹板治疗尺桡骨双骨折的生物力学实验研究[D].福建中医学院,2002.
[25]欧来良,王志彬,李林安,等.柳木夹板力学性能测试和优化分析.中国骨伤,2000,13(10):580-582.
[26]Tencer AF,ViegasS F,Cantrell J,et al.Pressure distribution in the wrist joint.J Orthop Res.1998;6(4):509-517.
[27]钦斌,黄永火,欧阳羽,等.轴向应力作用下的舟骨有限元分析[J].第三军医大学学报,2010,15(11):1213-1215.
[28]周晓宁.腕关节三维有限元模型的建立及桡骨远端骨折发生机制的生物力学分析[D].北京中医药大学,2014.
[29]Schuind F,An KN,Berglund L,et al.The distal radioulnar ligaments:A Biomechanical study.J Hand Surg Am.1991;16(6):1106-1114.
[30]Short WH,werner FW,Fortino MD,et al.The stabilizing mechanism of the distal radioulnar joint during pronation and supination.J Hand Surg Am.1995;20(6):930-936.
[31]Cheng HY,Lin CL,Lin YH,et al.Biomechanical evaluation of the modified Double-Plating fixation for the distal radius fracture.Clin Biomechanics(Bristol,Avon).2007;22(5):510-517.
[32]李想.小夹板治疗老年桡骨远端骨折中夹板束缚力的量化研究[D].广州中医药大学,2011.
[33]兰美兵,敖俊,张美超.两种植骨方式治疗L-1椎体爆裂骨折的有限元研究[J].中国临床解剖学杂志,2016,34(1):91-95.
[34]Yu B,Chen W C,Lee P Y,et al.Biomechanical comparison of conventional and anatomical calcaneal plates for the treatment of intraarticular calcaneal fractures-a finite element study.Comput Methods Biomech Biomed Engin.2016;19(13):1363-1370.
[35]Burt LA,Macdonald HM,Hanley DA,et al.Bone microarchitecture and strength of the radius and tibia in a reference population of young adults:an HR-p QCT study.Arch Osteoporos.2014;9(1):183.
[36]Noda M,Saegusa Y,Takahashi M,et al.Biomechanical study using the finite element method of i Internal fixation in pauwels typeⅢvertical femoral neck fractures.Arch Trauma Res.2015;4(3):e23167.
[37]林蔚莘.斜T型钢板内固定治疗桡骨远端骨折的有限元分析[D].南方医科大学,2004.
[38]李瑛,费攀,邹季.再议小夹板弹性固定骨折的先进性和科学性[J].中医外治杂志,2009,18(1):3-4.
[2]Rikli DA,Regazzoni P.Fractures of the distal end of the radius treated by internal fixation and early function.A preliminary report of 20 cases.J Bone Joint Surg Br.1996;78(4):588-592.
[3]Henry MH.Management acute triangular fibrocartilage complex injury of the wrist.J Am Acad Orthop Surg.2008,16(6):320-329.
[4]Anderson ML,Larson AN,Moran SL,et al.Clinical comparison of arthroscopic versus open repair of triangular fibrocartilage complex tears.J Hand Surg Am.2008;33(5):675-682.
[5]Abe Y,Moriya A,Tominaga Y,et al.Dorsal tear of triangular fibrocartilage complex:clinical features and treatment.J Wrist Surg.2016;5(1):42-46.
[6]杨焕,王斌,李浩,等.尺骨茎突解剖特点与骨折分型及治疗方法[J].中国临床解剖学杂志,2012,30(5):564-567.
[7]Woo SJ,Jegal M,Park MJ.Arthroscopic-assisted repair of triangular fibrocartilage complex foveal avulsion in distal radioulnar joint injury.Indian J Orthop.2016;50(3):263-268.
[8]Moritomo H.The distal interosseous membrane:current concepts in wrist anatomy and biomechanics.J Hand Surg Am.2012;37(7):1501-1507.
[9]Zlatkin M B,Rosner J.MR imaging of ligaments and triangular fibrocartilage complex of the wrist.Radiol Clin North Am.2006;44(4):595-623.
[10]尚峥辉,黄富国,岑石强,等.三角纤维软骨复合体损伤后腕关节稳定性的生物力学分析[J].中国修复重建外科杂志,2008,22(7):820-823.
[11]张光辉.桡骨远端骨折合并的尺骨茎突骨折内固定与否对腕关节功能的影响[J].临床医药文献电子杂志,2016,3(41):8162-8164.
[12]Ayalon O,Marcano A,Paksima N,et al.Concomitant ulnar styloid fracture and distal radius fracture portend poorer outcome.Am J Orthop.2016;45(1):34-37.
[13]Yilmaz S,Cankaya D,Karakus D.Ulnar styloid fracture has no impact on the outcome but decreases supination strength after conservative treatment of distal radial fracture.2015;20(8):1497-1502.
[14]Kr?mer S,Meyer H,O'Loughlin P F,et al.The incidence of ulnocarpal complaints after distal radial fracture in relation to the fracture of the ulnar styloid.J Hand Surg Eur Vol.2013;38(7):710-717.
[15]Shirakawa K,Shirota M.T.A.C.Pin fixation for basal ulnar styloid fractures associated with distal radius fractures.Tech Hand Up Extrem Surg.2013;17(3):158-161.
[16]靳家骋,张坤鹏,黄富国.合并尺骨茎突骨折对桡骨远端骨折预后影响的Meta分析[J].中国循证医学杂志,2014,14(6):729-733.
[17]赵雪明,都晋江.前后石膏夹板固定治疗桡骨远端骨折68例疗效分析[J].临床医药实践,2009,18(9):719-720.
[18]Kang YK,Park HC,Youm Y,et al.Three dimensional shape reconstruction and finite element analysis of femur before and after the cementless type of total hip replacement.J Biomed Eng.1993;15:497-504.
[19]Lotz JC,Cheal EJ,Hayes WC.Fracture prediction for the proximal femur using finite element models:partl-linear analysis.J Biomech Engin.1991;11(2):353-360.
[20]徐永清,钟世镇,徐达传,等.腕关节韧带的解剖学研究[J].创伤外科杂志,2006,8(1):52-54.
[21]颜冰珊.尺骨茎突骨折与下尺桡关节稳定性关系的有限元分析[D].复旦大学,2009.
[22]郭欣,樊瑜波,李宗明.掌骨受轴向压力作用下的腕部生物力学分析[J].航天医学与医学工程,2008,21(1):45-49.
[23]Anderson DD,Daniel TE.A contact-coupled finite element analysis of the radiocarpal joint.Semin Arthroplasty.1995;6(1):30-36.
[24]周恩昌.塑形夹板治疗尺桡骨双骨折的生物力学实验研究[D].福建中医学院,2002.
[25]欧来良,王志彬,李林安,等.柳木夹板力学性能测试和优化分析.中国骨伤,2000,13(10):580-582.
[26]Tencer AF,ViegasS F,Cantrell J,et al.Pressure distribution in the wrist joint.J Orthop Res.1998;6(4):509-517.
[27]钦斌,黄永火,欧阳羽,等.轴向应力作用下的舟骨有限元分析[J].第三军医大学学报,2010,15(11):1213-1215.
[28]周晓宁.腕关节三维有限元模型的建立及桡骨远端骨折发生机制的生物力学分析[D].北京中医药大学,2014.
[29]Schuind F,An KN,Berglund L,et al.The distal radioulnar ligaments:A Biomechanical study.J Hand Surg Am.1991;16(6):1106-1114.
[30]Short WH,werner FW,Fortino MD,et al.The stabilizing mechanism of the distal radioulnar joint during pronation and supination.J Hand Surg Am.1995;20(6):930-936.
[31]Cheng HY,Lin CL,Lin YH,et al.Biomechanical evaluation of the modified Double-Plating fixation for the distal radius fracture.Clin Biomechanics(Bristol,Avon).2007;22(5):510-517.
[32]李想.小夹板治疗老年桡骨远端骨折中夹板束缚力的量化研究[D].广州中医药大学,2011.
[33]兰美兵,敖俊,张美超.两种植骨方式治疗L-1椎体爆裂骨折的有限元研究[J].中国临床解剖学杂志,2016,34(1):91-95.
[34]Yu B,Chen W C,Lee P Y,et al.Biomechanical comparison of conventional and anatomical calcaneal plates for the treatment of intraarticular calcaneal fractures-a finite element study.Comput Methods Biomech Biomed Engin.2016;19(13):1363-1370.
[35]Burt LA,Macdonald HM,Hanley DA,et al.Bone microarchitecture and strength of the radius and tibia in a reference population of young adults:an HR-p QCT study.Arch Osteoporos.2014;9(1):183.
[36]Noda M,Saegusa Y,Takahashi M,et al.Biomechanical study using the finite element method of i Internal fixation in pauwels typeⅢvertical femoral neck fractures.Arch Trauma Res.2015;4(3):e23167.
[37]林蔚莘.斜T型钢板内固定治疗桡骨远端骨折的有限元分析[D].南方医科大学,2004.
[38]李瑛,费攀,邹季.再议小夹板弹性固定骨折的先进性和科学性[J].中医外治杂志,2009,18(1):3-4.