高能量创伤性桡骨远端粉碎性骨折的治疗

The treatment of comminuted distal radius fractures caused by high-energy injuries

目的回顾分析闭合复位、单侧外固定器跨腕关节静力性固定治疗高能量创伤性桡骨远端粉碎性骨折的疗效。方法2000年6月～2003年6月,20例(24处)桡骨远端粉碎性骨折患者,男16例,女4例;年龄15～48岁,平均33.4岁;左侧12例,右侧4例,双侧4例。骨折分型均为FrykmanⅧ型或AOC3型。采用手法或外固定器协助复位,外固定器静力性固定。骨折愈合时间6～8周,平均7.4周。骨折愈合后拆除外固定器,行腕关节屈伸、桡偏、尺偏及前臂旋前、旋后等功能锻炼。结果20例患者均获得随访,随访时间6～42个月,平均16个月。末次随访时,桡骨远端位置的影像学评估(Stewart改良的Sarmiento评分)优17例(21处),良3例(3处);腕关节功能评分(Gartland-Werley功能评分)优13例(16处),良5例(6处),可2例(2处)。2例2处出现针道表浅感染,经口服抗生素及局部换药后好转;5例(7处)骨折复位后干骺端出现明显的骨缺损,未经任何处理,骨折愈合时骨缺损消失。无一例出现骨性针道感染、松动、医原性骨折及桡神经浅支损伤等并发症。结论闭合复位、单侧外固定器跨腕关节静力性固定是治疗高能量创伤性桡骨远端粉碎性骨折的有效方法,无须植骨,通过选择合适的外固定针置入部位,可以减少并发症的发生,有利于术后早期进行手部功能锻炼。

Objective To analyze retrospectively the results of closed reduction and static transarticular fixation with unilateral external fixators in the treatment of severely comminuted distal radius fractures caused by high-energy injuries. Methods From June 2000 to June 2003, 20 patients with 24 severely comminuted distal radius fractures were treated with closed reduction and static transarticular fixation with unilateral external fixator. The injuries involved 16 males and 4 females, the age of the patients was from 15 to 48 years (average 33.4 years). All fractures were classified as Frykman's type Ⅷ or AO type C3. The operative technique consisted of reduction of the fractures by manipulation or assisted with the external fixator, then fixed them statically. The mean duration of the union was 7.4 weeks (ranged from 6-8 weeks). After the fixator removal, the patients were encouraged to proceed for the rehabilitations, such as the elbow flexion-extension, radial abduction, ulnar adduction, and the pronation as well as the supination of the forearm. Results All patients were available at the final follow-up, the mean duration was 16 months (range, 6-42 months). At the last examination, the radiological manifestations revealed excellent in 21 fractures (17 patients) and good in 3 (3 patients) according to the Sarmiento scoring system (modified by Stewart); and the functional results displaied excellent in 16 (13 patients), good in 6 (5 patients) and fair in 2 (2 patients) according to Gartland-Werley functional assessment system. There were only 2 cases of superficial pin site infection cured with oral antibiotics and local care with mild disinfectants. 7 obvious defect of mataphysis occurred in 5 patients, but the fractures united simultaneously without any additional treatment. And there was no any complication, such as pin tract infection, fixator loosening, iatrogenic fracture and injury of the superficial radial nerve. Conclusion The technique of closed reduction by manipulations or external fixators combined with static transarticular fixation plus unilateral external fixators is an effective method for the treatment of severely comminuted distal radius fracture caused by high-energy injuries, such as falling from the height. It is unnecessary to apply supplementary bone grafts to promote bone healing. The complications can be avoided by selecting the right sites for the insertion of the pins, which is beneficial for the hand to mobilize earlier after operation.