桡骨远端骨折畸形愈合后腕关节的生物力学变化
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摘要
目的：临床上桡骨远端骨折非常常见，畸形愈合是桡骨远端骨折的常见并发症和后遗症。畸形愈合常导致患者的腕关节疼痛、活动度的下降以及关节炎的发生。本研究的目的是：探讨桡骨远端畸形愈合以后，腕骨（包括舟骨、月骨、三角骨及头状骨）的运动学改变，桡腕关节（包括桡舟关节和桡月关节）的接触面的移位，和腕关节韧带长度的改变。
研究方法：招募桡骨远端骨折畸形愈合后的病人，纳入标准为：单侧桡骨远端骨折，骨折至实验时的时间>6个月，年龄>18岁，-10°<掌倾角<-20°，尺骨正变异<3mm。健侧手腕无外伤史，无风湿、类风湿、痛风等疾病，无系统性疾病及药物酒精滥用史。共有8例志愿者进行基本信息采集。其中，女性7例，男性1例，平均年龄：60岁（53岁～75岁）。平均受伤时间20个月（7个月～44个月）。患侧掌倾角平均为-14.9°（-10.5°～-19.7°）。尺骨正变异平均为1.9mm（0.8mm～2.8mm）。将双侧腕关节分别固定在中立位、尺偏20°、掌屈20°、背伸20°和背伸40°5个位置，利用CT进行扫描。通过计算机软件Mimics10.01、Magics13.0及Geomagic11.0将腕关节各腕骨、桡骨远端和尺骨远端三维重建后，对腕骨（包括舟骨、月骨、三角骨及头状骨）的运动学改变，桡腕关节（包括桡舟关节和桡月关节）的接触面的移位，和腕部韧带长度的改变进行研究。
结果：本研究结果包括3部分。一、腕骨的运动学：桡骨远端骨折畸形愈合以后，与健侧腕关节相比，舟骨、月骨、三角骨及头状骨发生显著的掌屈（p<0.05或p<0.01），旋前、旋后及桡偏、尺偏无明显变化；在尺偏20°或背伸20°时，舟骨发生显著的桡偏；三角骨在中立位、掌屈20°、背伸20°时，发生显著的尺偏。二、桡腕关节的接触面。中立位时，桡舟关节面的接触中心显著的移向舟骨窝的背侧，在掌屈20°时，桡舟关节接触面中心点显著的移向月骨窝的尺背侧。桡月关节面的接触中心显著移向月骨窝的尺侧。三、腕关节的韧带长度变化。患侧背侧桡腕韧带（DRC），在中立位、尺偏20°、掌屈20°时，较健侧腕关节显著拉长。长桡月韧带（LRL）显著短缩。尺三角韧带（UT）在尺偏20°和背伸20°时显著拉长。
结论：桡骨远端骨折伴有中度背伸畸形愈合后，舟骨、月骨、三角骨及头状骨的运动学发生显著的掌屈。桡舟关节及桡月关节接触面的中心点发生了显著的移位。腕关节韧带中，背侧桡腕韧带（DRC）、长桡月韧带（LRL）和尺三角韧带（UT）的长度发生了变化。
Background: Patients with a malunited distal radius often have painful and limitedulnar deviation and flexion and extension. The purpose of this study was to determine ifthe kinematics of carpal bones, radiocarpal contact areas, and the length of carpalligaments were altered in patients with malunited distal radius fractures.
Methods: We obtained computed tomography scans of the wrists of8volunteers withone side malunited distal radius fractures at5positions for both wrists: the neutral positionof the carpus;20°of ulnar deviation;20°of flexion;20°of extension; and40°of extension.The malunited distal radius fractures have dorsal angulation between10°and20°(average14.9±4.1°) and the ulnar variation≤3mm. The3-dimensional carpal and distal radioulnarjoint structures were acquired with customized software. We analyzed changes in thekinematics of scaphoid, lunate, triquetrum, and capitate, the center of contact areas of theradiocarpal joints, and the lengths of8palmar and dorsal wrist ligaments for both thenormal and dieased wrists.
Results: The results contained3parts: First, the kinematics of the carpal bones. In ourstudy, the capitate, scaphoid, lunate, and triquetrum were significantly more flexed in thewrist with malunited distal radius (p<0.05or p<0.01) compared with the contralateraluninjured side, but we found no significant changes in pronation or supination at all of the5positions. Scaphoid was significantly more radial deviated when the wrist was placed atulnar deviation20°or at extension20°; Triquetrum was significantly more ulnarly deviatedat neutral,20°of flexion, and20°of extension of the wrist. Second, at the neutral position,the center of the radioscaphoid articular contact site was significantly translated to thedorsal of the scaphoid fossa compared with the uninjured wrist. When the wrist flexed20°,the center of the radioscaphoid articular contact site was significantly shifted to the dorsaland ulnar of scaphoid fossa; The center of the radiolunate articular contact map wassignificantly shifted to the ulnar of lunate fossa; Third, the dorsal radiocarpal (DRC)ligament was significantly lengthened at neutral,20°of ulnar deviation, and20°of flexion.The long radiolunate ligament (LRL) was significantly shortened at neutral position. The UT ligment was significantly lengthened at20°of ulnar deviation, and20°of extension.
Conclusions: With mild degree of dorsal angulated malunion of the distal radiusfracture (average dorsal tilt:14.9°±4.1°), significant and drastic changes in radioscaphoidand radiolunate contact characteristics,3-D positions of carpal bones, and in vivo length ofprincipal wrist ligaments occur. The changes are seen at multiple wrist positions, especiallyat neutral, ulnar deviation, and extension.
研究方法：招募桡骨远端骨折畸形愈合后的病人，纳入标准为：单侧桡骨远端骨折，骨折至实验时的时间>6个月，年龄>18岁，-10°<掌倾角<-20°，尺骨正变异<3mm。健侧手腕无外伤史，无风湿、类风湿、痛风等疾病，无系统性疾病及药物酒精滥用史。共有8例志愿者进行基本信息采集。其中，女性7例，男性1例，平均年龄：60岁（53岁～75岁）。平均受伤时间20个月（7个月～44个月）。患侧掌倾角平均为-14.9°（-10.5°～-19.7°）。尺骨正变异平均为1.9mm（0.8mm～2.8mm）。将双侧腕关节分别固定在中立位、尺偏20°、掌屈20°、背伸20°和背伸40°5个位置，利用CT进行扫描。通过计算机软件Mimics10.01、Magics13.0及Geomagic11.0将腕关节各腕骨、桡骨远端和尺骨远端三维重建后，对腕骨（包括舟骨、月骨、三角骨及头状骨）的运动学改变，桡腕关节（包括桡舟关节和桡月关节）的接触面的移位，和腕部韧带长度的改变进行研究。
结果：本研究结果包括3部分。一、腕骨的运动学：桡骨远端骨折畸形愈合以后，与健侧腕关节相比，舟骨、月骨、三角骨及头状骨发生显著的掌屈（p<0.05或p<0.01），旋前、旋后及桡偏、尺偏无明显变化；在尺偏20°或背伸20°时，舟骨发生显著的桡偏；三角骨在中立位、掌屈20°、背伸20°时，发生显著的尺偏。二、桡腕关节的接触面。中立位时，桡舟关节面的接触中心显著的移向舟骨窝的背侧，在掌屈20°时，桡舟关节接触面中心点显著的移向月骨窝的尺背侧。桡月关节面的接触中心显著移向月骨窝的尺侧。三、腕关节的韧带长度变化。患侧背侧桡腕韧带（DRC），在中立位、尺偏20°、掌屈20°时，较健侧腕关节显著拉长。长桡月韧带（LRL）显著短缩。尺三角韧带（UT）在尺偏20°和背伸20°时显著拉长。
结论：桡骨远端骨折伴有中度背伸畸形愈合后，舟骨、月骨、三角骨及头状骨的运动学发生显著的掌屈。桡舟关节及桡月关节接触面的中心点发生了显著的移位。腕关节韧带中，背侧桡腕韧带（DRC）、长桡月韧带（LRL）和尺三角韧带（UT）的长度发生了变化。
Background: Patients with a malunited distal radius often have painful and limitedulnar deviation and flexion and extension. The purpose of this study was to determine ifthe kinematics of carpal bones, radiocarpal contact areas, and the length of carpalligaments were altered in patients with malunited distal radius fractures.
Methods: We obtained computed tomography scans of the wrists of8volunteers withone side malunited distal radius fractures at5positions for both wrists: the neutral positionof the carpus;20°of ulnar deviation;20°of flexion;20°of extension; and40°of extension.The malunited distal radius fractures have dorsal angulation between10°and20°(average14.9±4.1°) and the ulnar variation≤3mm. The3-dimensional carpal and distal radioulnarjoint structures were acquired with customized software. We analyzed changes in thekinematics of scaphoid, lunate, triquetrum, and capitate, the center of contact areas of theradiocarpal joints, and the lengths of8palmar and dorsal wrist ligaments for both thenormal and dieased wrists.
Results: The results contained3parts: First, the kinematics of the carpal bones. In ourstudy, the capitate, scaphoid, lunate, and triquetrum were significantly more flexed in thewrist with malunited distal radius (p<0.05or p<0.01) compared with the contralateraluninjured side, but we found no significant changes in pronation or supination at all of the5positions. Scaphoid was significantly more radial deviated when the wrist was placed atulnar deviation20°or at extension20°; Triquetrum was significantly more ulnarly deviatedat neutral,20°of flexion, and20°of extension of the wrist. Second, at the neutral position,the center of the radioscaphoid articular contact site was significantly translated to thedorsal of the scaphoid fossa compared with the uninjured wrist. When the wrist flexed20°,the center of the radioscaphoid articular contact site was significantly shifted to the dorsaland ulnar of scaphoid fossa; The center of the radiolunate articular contact map wassignificantly shifted to the ulnar of lunate fossa; Third, the dorsal radiocarpal (DRC)ligament was significantly lengthened at neutral,20°of ulnar deviation, and20°of flexion.The long radiolunate ligament (LRL) was significantly shortened at neutral position. The UT ligment was significantly lengthened at20°of ulnar deviation, and20°of extension.
Conclusions: With mild degree of dorsal angulated malunion of the distal radiusfracture (average dorsal tilt:14.9°±4.1°), significant and drastic changes in radioscaphoidand radiolunate contact characteristics,3-D positions of carpal bones, and in vivo length ofprincipal wrist ligaments occur. The changes are seen at multiple wrist positions, especiallyat neutral, ulnar deviation, and extension.
引文
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