Colles骨折复位后致急性腕管综合征22例临床分析

CLINICAL ANALYSIS OF ACUTE CARPAL TUNNEL SYNDROME AFTER REDUCTION OF Colles’ FRACTURE IN TWENTY-TWO PATIENTS

目的探讨Colles骨折复位后发生急性腕管综合征(acute carpal tunnel syndrome,ACTS)的病因及诊疗方法。方法 2006年12月-2010年6月收治22例Colles骨折复位后发生ACTS的患者。男9例,女13例;年龄23～60岁,平均46.2岁。致伤原因:交通事故伤9例,跌伤8例,高处坠落伤2例,打击伤2例,砸伤1例。致伤机制:直接暴力3例,间接暴力19例。根据Gartland&Werley的Colles骨折分型标准:Ⅰ型2例,Ⅱ型5例,Ⅲ型14例,Ⅳ型1例。手法闭合复位石膏外固定治疗19例,切开复位内固定(open reduction and internal fi xation,ORIF)治疗3例。骨折复位后至出现ACTS时间:闭合复位为1 h 30 min～48 h,平均11.6 h;ORIF 1例24 h、2例2周。首先进行保守治疗,闭合复位石膏外固定者改为前臂中立位固定,固定1周后症状无缓解者,每周注射糖皮质激素1次,共2周;ORIF患者直接腕管内注射糖皮质激素。保守治疗无效者再次行ORIF。结果 7例Ⅲ型患者保守治疗无效,再次行ORIF后ACTS症状均消失。患者均获随访,随访时间8～18个月,平均12个月。正中神经卡压症状完全消失时间为2～25 d,平均11 d。所有患者手指活动、感觉正常,麻木、刺痛感消失,拇指对掌功能正常。叩击试验(Tinel征)、腕掌屈试验、腕背伸试验均为阴性。X线片检查示骨折复位、愈合良好,愈合时间为3～14周,平均6周。末次随访时参照顾玉东的腕管综合征功能评定标准:获优18例,良4例,优良率100%。结论 Colles骨折错误复位、术后骨折移位、腕关节掌屈尺偏位是导致ACTS发生的主要原因。对于Ⅰ、Ⅱ、Ⅳ型Colles骨折患者首选保守治疗,Ⅲ型骨折患者首选手术治疗。

Objective To investigate the etiology,diagnosis,and treatment of acute carpal tunnel syndrome（ACTS） after reduction of Colles’ fracture.Methods Between December 2006 and June 2010,22 patients with ACTS after reduction of Colles’ fracture were treated with expectant treatment and surgical treatment.There were 9 males and 13 females with an average age of 46.2 years（range,23-60 years）.Fractures were caused by traffic accident in 9 cases,falling in 8 cases,falling from height in 2 cases,hitting in 2 cases,and crushing in 1 case.The mechanism of fracture was direct violence in 3 cases and indirect violence in 19 cases.According to Gartland Werley classification,there were 2 cases of type Ⅰ,5 cases of type II,14 cases of type Ⅲ,and 1 case of type IV.Closed reduction was performed in 19 cases and open reduction and internal fixation（ORIF） in 3 cases.The average symptom time of ACTS after reduction of Colles’ fracture was 11.6 hours（range,1 hour 30 minutes to 48 hours） in patients undergoing closed reduction and was 24 hours in 1 patient and 2 weeks in 2 patients undergoing ORIF.Expectant treatment was performed first,the forearms were put in neutral position in closed reduction cases;if there was no relief of ACTS symptom 1 week later,the mixture of 1 mL glucocorticosteroid and 1 mL 2% lidocaine was injected into carpal tunnel once a week for 2 weeks.The mixture was injected into carpal tunnel directly once a week for 2 weeks in ORIF cases.In the patients who failed to expectant treatments,ORIF was performed.Results In 7 cases of type III that failed expectant treatment,ACTS symptoms were relief completely after ORIF.All the 22 patients were followed up 12 months on average（range,8-18 months）.The average time of complete disappearance of median nerve compression symptom was 11 days（range,2-25 days）.All the patients had normal finger motion,sensation,and opposition of thumb with no sensation of anaesthesia and pinprick.The results of Tinel test,Phalen test,and Reverse Phalen test were all negative.The X-ray film showed good fracture reduction and healing with an average healing time of 6 weeks（range,3-14 weeks）.According to GU Yudong’s criteria for functional assessment,the results were excellent in 18 cases and good in 4 cases;the excellent and good rate was 100%.ConclusionMalposition,displacement of fracture fragments,and ulnar deviation of the wrist after plaster immobilization are the most important risk factors for ACTS.Expectant treatments are recommended in patients with Colles’ fracture of types Ⅰ,Ⅱ,and Ⅳ,but surgical treatment is the first choice for Colles’ fracture of type III.