不同手术方式治疗桡骨远端骨折的疗效比较
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摘要
目的比较不同手术方式治疗桡骨远端粉碎性骨折的临床疗效。方法将2012年1月至2016年12月我科收治的210例桡骨远端骨折患者作为研究对象,按主要骨折块移位类型和骨折粉碎程度分为3组,其中A组58例采用背侧入路切开复位单钢板固定,B组69例采用背侧入路切开复位双钢板固定,C组83例采用掌侧入路切开复位单钢板固定。比较3组患者骨折复位效果、软组织情况、临床愈合时间、伤口感染率及腕关节功能评价的差异。结果 3组患者在桡骨高度、掌倾角和尺偏角上比较,差异无统计学意义(P> 0. 05);在临床愈合时间上差异无统计学意义(P> 0. 05);在肌腱刺激征上,A组明显高于B组和C组,差异有统计学意义(P <0. 05);手术9个月后,分别通过DASH上肢功能调查表和PRWE评分从不同侧重方向对3组腕关节功能进行评价分析,A组与B组、C组差异均有统计学意义(P <0. 05)。结论掌侧入路可适用于大多数桡骨远端关节内骨折,其在骨折复位、钢板放置和规避肌腱损伤等方面具有优势,但存在正中神经和桡动脉损伤风险,对手术技术有一定要求;背侧入路双钢板固定可提供双柱的稳定性、可直视关节面,对于严重粉碎背侧关节面的处理复位有一定优势,但存在伸肌腱激惹的风险;背侧单钢板固定,在固定强度和远期功能及并发症的防治上均不具有优势。手术方式的选择应结合骨折粉碎程度、移位类型、术区皮肤软组织条件以及患者对腕关节功能要求等多方面的情况来确定。
Objective To compare the clinical efficacy of different surgical methods in the treatment of comminuted distal radius fracture. Methods A total of 210 patients with distal radius fractures in our department from January 2012 to December 2016 were divided into group A,B,C according to fracture displacement type and degree of comminuted fracture; 58 cases in group A were treated with open reduction and single plate fixation via dorsal approach,69 cases in group B were treated with open reduction and double plate fixation via dorsal approach,and 83 cases in group C were treated with open reduction and single plate fixation via volar approach. The differences of reduction effect,soft tissue condition,clinical healing time,complications and wrist joint function of the three groups were compared. Results There was no statistical difference in radius height,palm inclination and ulnar deviation between three groups( P > 0. 05). No statistical difference was found in clinical healing time( P > 0. 05). The tendon irritation signs of group A was significantly higher than those of group B and group C,the differences were significant( P < 0. 05). After 9 months of operation,DASH upper limb function questionnaire and PRWE score were used to evaluate the wrist joint function of three groups from different directions. There were statistical differences between group A and other two groups in scoring. Conclusion The volar approach can be applied to most distal radial intra-articular fractures. It has advantages in fracture reduction,plate placement and tendon injury avoidance,but there is a risk of median nerve and radial artery injury,which requires certain surgical techniques. Dorsal approach with double plate fixation can provide stability of the double column and can directly look at the joint surface. It has certain advantages for the treatment and reduction of severe crushing of the dorsal joint surface,but there is a risk of extensor tendon irritation. Dorsal single plate fixation has no advantages in fixation strength,long-term function and the prevention and treatment of complications. At the same time,there are individual differences in the choice of surgical methods,which should be determined in combination with the degree of fracture comminution,type of displacement,skin and soft tissue conditions in the operative area,as well as the patient's requirements on wrist function and other aspects.
Objective To compare the clinical efficacy of different surgical methods in the treatment of comminuted distal radius fracture. Methods A total of 210 patients with distal radius fractures in our department from January 2012 to December 2016 were divided into group A,B,C according to fracture displacement type and degree of comminuted fracture; 58 cases in group A were treated with open reduction and single plate fixation via dorsal approach,69 cases in group B were treated with open reduction and double plate fixation via dorsal approach,and 83 cases in group C were treated with open reduction and single plate fixation via volar approach. The differences of reduction effect,soft tissue condition,clinical healing time,complications and wrist joint function of the three groups were compared. Results There was no statistical difference in radius height,palm inclination and ulnar deviation between three groups( P > 0. 05). No statistical difference was found in clinical healing time( P > 0. 05). The tendon irritation signs of group A was significantly higher than those of group B and group C,the differences were significant( P < 0. 05). After 9 months of operation,DASH upper limb function questionnaire and PRWE score were used to evaluate the wrist joint function of three groups from different directions. There were statistical differences between group A and other two groups in scoring. Conclusion The volar approach can be applied to most distal radial intra-articular fractures. It has advantages in fracture reduction,plate placement and tendon injury avoidance,but there is a risk of median nerve and radial artery injury,which requires certain surgical techniques. Dorsal approach with double plate fixation can provide stability of the double column and can directly look at the joint surface. It has certain advantages for the treatment and reduction of severe crushing of the dorsal joint surface,but there is a risk of extensor tendon irritation. Dorsal single plate fixation has no advantages in fixation strength,long-term function and the prevention and treatment of complications. At the same time,there are individual differences in the choice of surgical methods,which should be determined in combination with the degree of fracture comminution,type of displacement,skin and soft tissue conditions in the operative area,as well as the patient's requirements on wrist function and other aspects.
引文
[1]张磊,王宸,常青,等.桡骨远端骨折的分型及治疗进展[J].东南大学学报(医学版),2015,34(3):472-475.doi:10.3969/j.issn.1671-6264.2015.03.036.
[2]Adnan K,Haluk C,Yunus O,et al.Flexor tendon complications in comminuted distal radius fractures treated with anatomic volar rim locking plates[J].Acta Orthop Traumatol Turc,2016,50(6):665-669.doi:10.1016/j.aott.2016.04.001.
[3]郑上团,吴斗,郝海虎,等.桡骨远端骨折的治疗进展[J].中华骨科杂志,2016,36(5):314-320.doi:10.3760/cma.j.issn.0253-2352.2016.05.009.
[4]樊健,蒋波,袁锋,等.桡骨远端骨折的临床特点及治疗策略[J].中华外科杂志,2016,54(10):766-771.doi:10.3760/cma.j.issn.0529-5815.2016.10.009.
[5]沈追孟.桡骨远端骨折不同预后评价标准的分析[D].浙江:浙江大学,2009.
[6]蔡宇,周华军,韩红,等.早期康复促进桡骨远端骨折术后腕关节功能康复的临床研究[J].中华手外科杂志,2016,32(5):374-376.doi:10.3760/cma.j.issn.1005-054X.2016.05.025.
[7]蒋泰媛,刘伟军,姚茂盘,等.手法复位后石膏夹板固定治疗桡骨远端骨折的疗效分析[J].内蒙古中医药,2016,35(15):56-57.doi:10.3969/j.issn.1006-0979.2016.15.053.
[8]曾荣东,张钰,孙炜俊,等.改良石膏外固定治疗老年人桡骨远端粉碎性骨折[J].中华老年医学杂志,2016,35(10):1107-1110.doi:10.3760/cma.j.issn.0254-9026.2016.10.020.
[9]俞军卫,吴成如,廖国权,等.老年桡骨远端骨折手术与非手术治疗的临床对照评价[J].安徽医学,2016,37(1):71-73.doi:10.3969/j.issn.1000-0399.2016.01.023.
[10]邢鸿基.手法复位小夹板外固定治疗老年桡骨远端骨折的效果[J].广州医科大学学报,2016,44(3):100-102.doi:10.3969/j.issn.1008-1836.2016.03.029.
[11]徐志国,张超,曹聪,等.桡骨远端骨折手术治疗及术后并发症[J].国际骨科学杂志,2013,34(3):178-181.doi:10.3969/j.issn.1673-7083.2013.03.009.
[12]李佳林,阳青松,苏佳灿.桡骨远端骨折手术治疗[J].国际骨科学杂志,2012,33(3):186-188.doi:10.3969/j.issn.1673-7083.2012.03.012.
[13]雷宁波,邢涛,董林.掌侧锁定钢板治疗桡骨远端骨折[J].临床骨科杂志,2016,19(5):632-633.doi:10.3969/j.issn.1008-0287.2016.05.051.
[14]杜发会,陈峰,毕明昊.桡骨远端万向掌侧锁定板治疗桡骨远端骨折38例[J].实用骨科杂志,2016,22(2):153-155.
[15]张军,王东昕.桡骨远端骨折术后合并拇长伸肌腱断裂的临床病因分析[J].大连医科大学学报,2016,38(6):583-586.doi:10.11724/jdmu.2016.06.15.
[16]康宝林,王东建,张鑫.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[J].实用骨科杂志,2016,22(3):272-274.
[17]彭军,周雪峰,白克文,等.双柱双接骨板技术治疗伴背侧骨质缺损的C型桡骨远端骨折30例[J].中华骨与关节外科杂志,2015,8(4):332-334.doi:10.3969/j.issn.2095-9958.2015.04-013.
[18]周欣,王伟,韦民.背侧双钢板治疗桡骨远端C型骨折[J].中国骨与关节损伤杂志,2014,29(5):509-510.doi:10.7531/j.issn.1672-9935.2014.05.044.
[19]智春升,邬波,金冶华,等.双锁定钢板内固定治疗AO C型桡骨远端双柱骨折的疗效分析[J].中国骨与关节损伤杂志,2016,31(1):102-104.doi:10.7531/j.issn.1672-9935.2016.01.041.
[20]王浩然.背侧入路双微型锁定加压钢板治疗桡骨远端粉碎骨折的效果[J].实用临床医药杂志,2017,21(1):121-122.doi:10.7619/jcmp.201701039.
[21]朱大安,路磊,方斌.背侧联合双钢板治疗桡骨远端背侧粉碎性骨折[J].浙江创伤外科,2014,19(2):244-245.doi:10.3969/j.issn.1009-7147.2014.02.041.
[22]史德军,吴巍巍,兰观华,等.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[J].中国微创外科杂志,2014,14(6):545-547.doi:10.3969/j.issn.1009-6604.2014.06.020.
[23]舒畅,陈虹炉,李智豪.掌背侧双钢板内固定治疗桡骨远端复杂不稳定性骨折[J].中医正骨,2017,29(1):63-66.doi:10.3969/j.issn.1001-6015.2017.01.015.
[24]张茗慧,李岳伟,李小荣.桡骨远端粉碎性骨折累及关节面手术治疗体会[J].实用临床医药杂志,2013,17(17):163-165.doi:10.7619/jcmp.201317062.
[25]黄俊明,张光明,王建炜,等.不同手术方法治疗AO分型C型桡骨远端骨折的疗效比较[J].广东医学,2012,33(13):1927-1929.doi:10.3969/j.issn.1001-9448.2012.13.027.
[2]Adnan K,Haluk C,Yunus O,et al.Flexor tendon complications in comminuted distal radius fractures treated with anatomic volar rim locking plates[J].Acta Orthop Traumatol Turc,2016,50(6):665-669.doi:10.1016/j.aott.2016.04.001.
[3]郑上团,吴斗,郝海虎,等.桡骨远端骨折的治疗进展[J].中华骨科杂志,2016,36(5):314-320.doi:10.3760/cma.j.issn.0253-2352.2016.05.009.
[4]樊健,蒋波,袁锋,等.桡骨远端骨折的临床特点及治疗策略[J].中华外科杂志,2016,54(10):766-771.doi:10.3760/cma.j.issn.0529-5815.2016.10.009.
[5]沈追孟.桡骨远端骨折不同预后评价标准的分析[D].浙江:浙江大学,2009.
[6]蔡宇,周华军,韩红,等.早期康复促进桡骨远端骨折术后腕关节功能康复的临床研究[J].中华手外科杂志,2016,32(5):374-376.doi:10.3760/cma.j.issn.1005-054X.2016.05.025.
[7]蒋泰媛,刘伟军,姚茂盘,等.手法复位后石膏夹板固定治疗桡骨远端骨折的疗效分析[J].内蒙古中医药,2016,35(15):56-57.doi:10.3969/j.issn.1006-0979.2016.15.053.
[8]曾荣东,张钰,孙炜俊,等.改良石膏外固定治疗老年人桡骨远端粉碎性骨折[J].中华老年医学杂志,2016,35(10):1107-1110.doi:10.3760/cma.j.issn.0254-9026.2016.10.020.
[9]俞军卫,吴成如,廖国权,等.老年桡骨远端骨折手术与非手术治疗的临床对照评价[J].安徽医学,2016,37(1):71-73.doi:10.3969/j.issn.1000-0399.2016.01.023.
[10]邢鸿基.手法复位小夹板外固定治疗老年桡骨远端骨折的效果[J].广州医科大学学报,2016,44(3):100-102.doi:10.3969/j.issn.1008-1836.2016.03.029.
[11]徐志国,张超,曹聪,等.桡骨远端骨折手术治疗及术后并发症[J].国际骨科学杂志,2013,34(3):178-181.doi:10.3969/j.issn.1673-7083.2013.03.009.
[12]李佳林,阳青松,苏佳灿.桡骨远端骨折手术治疗[J].国际骨科学杂志,2012,33(3):186-188.doi:10.3969/j.issn.1673-7083.2012.03.012.
[13]雷宁波,邢涛,董林.掌侧锁定钢板治疗桡骨远端骨折[J].临床骨科杂志,2016,19(5):632-633.doi:10.3969/j.issn.1008-0287.2016.05.051.
[14]杜发会,陈峰,毕明昊.桡骨远端万向掌侧锁定板治疗桡骨远端骨折38例[J].实用骨科杂志,2016,22(2):153-155.
[15]张军,王东昕.桡骨远端骨折术后合并拇长伸肌腱断裂的临床病因分析[J].大连医科大学学报,2016,38(6):583-586.doi:10.11724/jdmu.2016.06.15.
[16]康宝林,王东建,张鑫.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[J].实用骨科杂志,2016,22(3):272-274.
[17]彭军,周雪峰,白克文,等.双柱双接骨板技术治疗伴背侧骨质缺损的C型桡骨远端骨折30例[J].中华骨与关节外科杂志,2015,8(4):332-334.doi:10.3969/j.issn.2095-9958.2015.04-013.
[18]周欣,王伟,韦民.背侧双钢板治疗桡骨远端C型骨折[J].中国骨与关节损伤杂志,2014,29(5):509-510.doi:10.7531/j.issn.1672-9935.2014.05.044.
[19]智春升,邬波,金冶华,等.双锁定钢板内固定治疗AO C型桡骨远端双柱骨折的疗效分析[J].中国骨与关节损伤杂志,2016,31(1):102-104.doi:10.7531/j.issn.1672-9935.2016.01.041.
[20]王浩然.背侧入路双微型锁定加压钢板治疗桡骨远端粉碎骨折的效果[J].实用临床医药杂志,2017,21(1):121-122.doi:10.7619/jcmp.201701039.
[21]朱大安,路磊,方斌.背侧联合双钢板治疗桡骨远端背侧粉碎性骨折[J].浙江创伤外科,2014,19(2):244-245.doi:10.3969/j.issn.1009-7147.2014.02.041.
[22]史德军,吴巍巍,兰观华,等.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[J].中国微创外科杂志,2014,14(6):545-547.doi:10.3969/j.issn.1009-6604.2014.06.020.
[23]舒畅,陈虹炉,李智豪.掌背侧双钢板内固定治疗桡骨远端复杂不稳定性骨折[J].中医正骨,2017,29(1):63-66.doi:10.3969/j.issn.1001-6015.2017.01.015.
[24]张茗慧,李岳伟,李小荣.桡骨远端粉碎性骨折累及关节面手术治疗体会[J].实用临床医药杂志,2013,17(17):163-165.doi:10.7619/jcmp.201317062.
[25]黄俊明,张光明,王建炜,等.不同手术方法治疗AO分型C型桡骨远端骨折的疗效比较[J].广东医学,2012,33(13):1927-1929.doi:10.3969/j.issn.1001-9448.2012.13.027.