桡侧腕屈肌腱部分移位治疗第一腕掌关节陈旧性脱位
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摘要
目的：陈旧性第一腕掌关节脱位多由第一腕掌关节脱位（不伴有骨折）治疗不及时或治疗不得当而造成的，患者遗留有手部畸形及拇指活动受限，最终导致创伤性关节炎的形成，将严重影响手部功能。本文作者在第一腕掌关节及韧带的解剖学观察基础上，设计了桡背侧入路，切取部分桡侧腕屈肌腱，重建第一腕掌关节韧带并增强关节囊。根据解剖学观测及临床疗效，评价该方法治疗第一腕掌关节陈旧性脱位的可行性及疗效。
方法：（1）解剖观察6侧手部解剖标本第一腕掌关节及其周围韧带结构。（2）对2010年1月～2011年12月，本科收治的6例外伤性、陈旧性第一腕掌关节背侧脱位的患者，进行桡侧腕屈肌腱部分移位重建第一腕掌关节韧带。手术于臂丛神经阻滞麻醉下进行,使用上臂驱-止血带。采用第一腕掌关节桡背侧“S”形切口，分离、显露第一腕掌关节，垂直于第一掌骨纵轴，平行于拇指指甲，距关节面0.7～0.8cm处钻孔。整复第一掌关节克氏针固定。纵行切取桡侧腕屈肌腱桡侧半，将腱条由骨孔桡侧向尺侧穿过，经拇长展肌腱、拇短伸肌腱深面绕至腕掌侧，抽紧腱条后，绕过桡侧腕屈肌肌腱的近止点处，再抽紧并与自身缝合。术后于拇指对掌外展位石膏固定。6周后去除石膏及克氏针固定，进行功能练习。
结果：（1）解剖观察显示：第一腕掌关节周围5条韧带的存在，该5条韧带分别为第一骨间韧带、后斜韧带、背桡侧韧带、前斜韧带以及尺侧韧带。（2）术后对全部6例患者于术后3～14个月（平均10.5个月）进行随访。显示第一腕掌关节畸形消失，关节疼痛消失，拇指的灵活性、对捏力、关节运动范围均较术前明显改善；腕关节屈、伸活动度及肌力较术前无明显变化；影像学检查提示脱位的关节均达到解剖复位，均无复发，且关节面无退行性关节炎改变；根据患者随访结果采用Buck-Gramcko评分标准进行评定。结果显示本组患者术后得分51～56分，平均55.17分，全部6例均为优。
结论：根据解剖学特点，设计了桡侧腕屈肌腱部分移位治疗陈旧性第一腕掌关节脱位的术式，该术式操作简便，对第一腕掌关节损伤小，疗效较好，是治疗陈旧性第一腕掌关节脱位的方法之一。
Objective: Most of the first old carpometacarpal dislocation caused byinappropriate treatment or not timely treatment(except the bone fracture),Because of patients’ left hand deformity and limited thumb mobility willleading to the formation of traumatic arthritis eventually, affect the handfunction seriously. On the basis of the anatomy about the first carpometacarpaldislocation and ligamentous, we design to cut of radial and dorsal, cut thepart of the flexor carpi radialis muscle tendon, rebuild the first carpometacarpalioint ligament and to consolidate joint capsule. According to the anatomyobservation and curative effect to evaluate the feasibility and efficacy oftreating the first carpometacarpal joint old dislocation.
Methods:（1）Anatomical observation of the six sides of the handanatomic specimens carpometacarpal joint and its surrounding ligamentousstructures（2） Depends on the six patients whom dorsal dislocation of the firstcarpometacarpal which we had treated from January2010to December2011,Part of the flexor carpi radialis tendon shift to reconstruction of the firstcarpometacarpal joint ligament. The operation is on the basis of brachial plexusnerve block anaesthesia and use upper arm tourniquet. Making the incisionabout the dorsal oblique ligaments of the first carpometacarpal ioint like “S”,separation, revealed the first carpometacarpal joint, and making the firstmetacarpal bone longitudinal axis perpendicular, parallel the nail of thumb,distance from the articular surface about0.7～0.8cm. Using the Kirschner wirereset the first metacarpal joint. Longitudinal cut side of the flexor carpi radialistendon radial half, the lateral ulnar through the tendon from the bone holeradius by the longus tendon of exhibition pollicis brevis extensor tendon of the deep surface of Raozhi carpal, tightening tendon article around nearly the onlypoint over the flexor carpi radialis tendon, and then tightening with their ownsuture. After the thumb, palm outside the booth, and cast immobilization.6weeks after removal of plaster and Kirschner wire fixation, and functionalexercises.
Results:（1）Through anatomical studies we found that it have fiveligaments around the first carpometacarpal joint， respectively, for theiniermetacarpal ligameni, the dorsal radial ligament, the dorsal obliqueligament, the anterior oblique ligaments and the ulnaris ligaments.(2) Afteroperation about3～14month（saverage10.5months）,we follow up six patients.The first carpometacarpal joints articular malformation and joint paindisappeared. The pollical flexibility and joint movement improve obviously.compared with preoperative pinch strength, joint range of motion havesignificant improvement. Image examinations showed the dislocation of thejoint anatomic reduction, there was no recurrence, the articular facet have norecessive arthritis change: the patients’ results that we follow up are useBuck-Gramcko scoring standard. The patients get the average score is55.17,six patients are excellent.
Conclusion:According to the anatomy, we design to shift the part of theradiocarpus which to cure the first old carpometacarpal dislocation. Theprocedure is simple, good effect.It is a method to treat old dislocation of thefirst carpometacarpal joint.
方法：（1）解剖观察6侧手部解剖标本第一腕掌关节及其周围韧带结构。（2）对2010年1月～2011年12月，本科收治的6例外伤性、陈旧性第一腕掌关节背侧脱位的患者，进行桡侧腕屈肌腱部分移位重建第一腕掌关节韧带。手术于臂丛神经阻滞麻醉下进行,使用上臂驱-止血带。采用第一腕掌关节桡背侧“S”形切口，分离、显露第一腕掌关节，垂直于第一掌骨纵轴，平行于拇指指甲，距关节面0.7～0.8cm处钻孔。整复第一掌关节克氏针固定。纵行切取桡侧腕屈肌腱桡侧半，将腱条由骨孔桡侧向尺侧穿过，经拇长展肌腱、拇短伸肌腱深面绕至腕掌侧，抽紧腱条后，绕过桡侧腕屈肌肌腱的近止点处，再抽紧并与自身缝合。术后于拇指对掌外展位石膏固定。6周后去除石膏及克氏针固定，进行功能练习。
结果：（1）解剖观察显示：第一腕掌关节周围5条韧带的存在，该5条韧带分别为第一骨间韧带、后斜韧带、背桡侧韧带、前斜韧带以及尺侧韧带。（2）术后对全部6例患者于术后3～14个月（平均10.5个月）进行随访。显示第一腕掌关节畸形消失，关节疼痛消失，拇指的灵活性、对捏力、关节运动范围均较术前明显改善；腕关节屈、伸活动度及肌力较术前无明显变化；影像学检查提示脱位的关节均达到解剖复位，均无复发，且关节面无退行性关节炎改变；根据患者随访结果采用Buck-Gramcko评分标准进行评定。结果显示本组患者术后得分51～56分，平均55.17分，全部6例均为优。
结论：根据解剖学特点，设计了桡侧腕屈肌腱部分移位治疗陈旧性第一腕掌关节脱位的术式，该术式操作简便，对第一腕掌关节损伤小，疗效较好，是治疗陈旧性第一腕掌关节脱位的方法之一。
Objective: Most of the first old carpometacarpal dislocation caused byinappropriate treatment or not timely treatment(except the bone fracture),Because of patients’ left hand deformity and limited thumb mobility willleading to the formation of traumatic arthritis eventually, affect the handfunction seriously. On the basis of the anatomy about the first carpometacarpaldislocation and ligamentous, we design to cut of radial and dorsal, cut thepart of the flexor carpi radialis muscle tendon, rebuild the first carpometacarpalioint ligament and to consolidate joint capsule. According to the anatomyobservation and curative effect to evaluate the feasibility and efficacy oftreating the first carpometacarpal joint old dislocation.
Methods:（1）Anatomical observation of the six sides of the handanatomic specimens carpometacarpal joint and its surrounding ligamentousstructures（2） Depends on the six patients whom dorsal dislocation of the firstcarpometacarpal which we had treated from January2010to December2011,Part of the flexor carpi radialis tendon shift to reconstruction of the firstcarpometacarpal joint ligament. The operation is on the basis of brachial plexusnerve block anaesthesia and use upper arm tourniquet. Making the incisionabout the dorsal oblique ligaments of the first carpometacarpal ioint like “S”,separation, revealed the first carpometacarpal joint, and making the firstmetacarpal bone longitudinal axis perpendicular, parallel the nail of thumb,distance from the articular surface about0.7～0.8cm. Using the Kirschner wirereset the first metacarpal joint. Longitudinal cut side of the flexor carpi radialistendon radial half, the lateral ulnar through the tendon from the bone holeradius by the longus tendon of exhibition pollicis brevis extensor tendon of the deep surface of Raozhi carpal, tightening tendon article around nearly the onlypoint over the flexor carpi radialis tendon, and then tightening with their ownsuture. After the thumb, palm outside the booth, and cast immobilization.6weeks after removal of plaster and Kirschner wire fixation, and functionalexercises.
Results:（1）Through anatomical studies we found that it have fiveligaments around the first carpometacarpal joint， respectively, for theiniermetacarpal ligameni, the dorsal radial ligament, the dorsal obliqueligament, the anterior oblique ligaments and the ulnaris ligaments.(2) Afteroperation about3～14month（saverage10.5months）,we follow up six patients.The first carpometacarpal joints articular malformation and joint paindisappeared. The pollical flexibility and joint movement improve obviously.compared with preoperative pinch strength, joint range of motion havesignificant improvement. Image examinations showed the dislocation of thejoint anatomic reduction, there was no recurrence, the articular facet have norecessive arthritis change: the patients’ results that we follow up are useBuck-Gramcko scoring standard. The patients get the average score is55.17,six patients are excellent.
Conclusion:According to the anatomy, we design to shift the part of theradiocarpus which to cure the first old carpometacarpal dislocation. Theprocedure is simple, good effect.It is a method to treat old dislocation of thefirst carpometacarpal joint.
引文
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[19]刘英明,刘连祥,刘士生.自制加压顶垫外固定架治疗第一掌骨基底骨折[J].骨与关节损伤,2003,18(5):310.
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[2] Haines RW. Mechanism of rotation at the first carpo-metacarpal joint[J]. JAnat,1944,78(Pt1-2):44-46.
[3] Bojsen-Moller F. Usteoligamentous guidance of the movements of thehuman thumb[J]. Am J Anat,1976,147(1):71-80.
[4] Zancolli EA.Structural and Dynamic Bases of Hand Surgery[M].1979:110-135.
[5] Zancolli EA, Ziadenberg C, Zancolli E Jr.Biomechanics of thetrapeziometacarpal joint.Clin Orthop Relat Res.1987Jul;(220):14-26.
[6] Kauer JM.Functional anatomy of the carpometacarpal joint of thethumb[J]. Clin Orthop Relat Res,1987(220):7-13.
[7] Imaeda T,An KN,Cooney WP,et al.Anatomy of trapeziometacarpalligaments [J].J Hand Surg Am,1993,18(2):226-231.
[8] Lane LB, Eaton RG.Ligament reconstruction for the painful thumbcarpometacarpal joint[J]. Clin Orthop Relat Res,1987(220):52-57.
[9] Eaton RG，Lane LB, Littler JW,et al. Ligament Reconstruction for thepainful thumb carpometacarpal joint:A long-term assessment[J].J HandSurg Am,1984,9(5):692-699.
[10] Strauch RJ，Behrman MJ, Rosenwasser MP. Acute dislocation of thecarpometacarpal joint of the thumb, An anatomic and cadaver study[J]. JHand Surg Am,1994,19(1):93-98.
[11] Bettinger PC, Linscheid RL, Berger RA,et al,.An anatomic sutdy of thestbailizing ligmaents of the Trpaezium and Trapeziometacarpal joint[J].JHand Surg Am,1999,24(4):786-798.
[12]田青业,刘正津.拇指腕掌关节囊和韧带的形态特点及其临床意义[J].中国临床解剖学杂志,2002,20(2):117-124.
[13]隋志甫,刘飙,魏壮,等.拇指腕掌关节韧带的解剖学和相关力学研究及其对临床指导价值[J].中国实验诊断学,2005,9(2):265-267.
[14]刘飙,张巨,魏壮，等.拇指腕掌关节背桡韧带的解剖学及其临床应用[J].吉林大学学报：医学版,2006,32(4):681-682.
[15] Shah J, Patel M．Dislocation of the carpometacarpal joint of the thumb. Areport of four cases[J]. Clin Orthop Relat Res,1983,(175):166-169.
[16]谭宗奎,陈庄洪,徐永年,等.改良石膏托与鸭型铁丝固定器治疗第一掌骨基底部关节内骨折的效果比较[J].中国矫形外科杂志,1996,3(4):278-279.
[17]邸军,张学东,张亚宁.蝶形石膏治疗Bennet骨折脱位[J].中国骨伤,1999,12(6):34.
[18]王明喜,李金松,高飞,等.手法复位夹板外固定治疗第一腕掌关节脱位[J].中国骨伤,1998,11(2):74.
[19]刘英明,刘连祥,刘士生.自制加压顶垫外固定架治疗第一掌骨基底骨折[J].骨与关节损伤,2003,18(5):310.
[20]徐宏宇,王刚祥.Eaton-Littler术式治疗第一腕掌关节不稳定[J].中华手外科杂志,2011,27(2):126-127.
[21]宋一平,钟桂午,张发惠,等．部分桡侧腕屈肌腱瓣修复陈旧性第一腕掌关节脱位[J].实用手外科杂志,2002,16(4):238．
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[23]李之斌,李庆泰,王海宝.桡侧腕屈肌腱部分转位治疗陈旧性第一腕掌关节半脱位[J].中国骨伤,2005,18(3):160-161.
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