基于三柱理论的桡骨远端die-punch骨折类型探讨

Types of die-punch fracture of the distal radius based on three-column theory

目的探讨桡骨远端die-punch骨折（DPFDR）特点和基于三柱理论的骨折类型及应用价值。方法回顾性研究2007年6月至2017年6月无锡市第九人民医院骨科收治的560例诊断为DPFDR患者的影像学资料，男305例，女255例；年龄13—95岁，平均46．4岁。我们提出分型先根据三柱理论分为单柱DPFDR和双柱DPFDR。再根据骨折部位和形态学特点，前者进一步分为掌侧型、背侧型、劈裂型和塌陷型，后者进一步分为干骺端型、关节面型和混合型。选择2名影像学医师先深度学习我们提出的新分型方法后，再独立对100例DPFDR进行分型评价，结果行一致性检验。结果560例患者中单柱DPFDR65例，其中掌侧型3例，背侧型13例，劈裂型14例，塌陷型35例；双柱DPFDR495例，其中干骺端型130例，关节面型155例，混合型210例。观察者间的Kappa系数为0．877-0．937，观察者内的Kappa系数为0．916～0．959，具有高度一致性。结论由于受伤瞬间暴力性质和大小、受伤时手腕关节位置和患者骨质等情况的不同，轴向暴力传递至桡骨远端中间柱后除了发生中间柱不同类型die-punch骨折外，还可合并轻度不同类型桡侧柱骨折。该分型较好地反映了DPFDR波及部位和形态学等特点，一致性较高，对手术治疗和预后判断有一定参考价值。

Objective To investigate the characteristics and types of die-punch fracture of the distal radius （DPFDR） based on three-column theory as well as its application value. Methods The imaging data of 560 cases of DPFDR were reviewed which had been treated at The Ninth People＇ s Hospital of Wuxi from June 2007 to June 2017. They were 305 males and 255 females, aged from 13 to 95 years, with an average of 46. 4 years. According to the three-column theory, the 560 DPFDR cases were divided into a single column group and a double column group. According to the fracture site and morphology, the former was further characterized as volar, dorsal, split and collapse types while the latter as metaphyseal, articular sur-face and mixed types. After being familiarized with our new classification, 2 radiologists were asked to classify 100 cases of DPFDR independently. The inter-and intra-observer agreements were analyzed with Kappa statistics. Results There were 65 cases of single column DPFDR, including 3 ones of volar type, 13 ones of dorsal type, 14 ones of split type and 35 ones of collapse type; there were 495 cases of double column DPFDR, including 130 ones of metaphyseal type, 155 ones of articular surface type and 210 ones of mixed type. The intra-observer Kappa coefficient was 0. 877-0. 937 and the intra-observer kappa was O. 916-0. 959, showing high agreement. Condusions Due to differences in violence nature and in-tensity, wrist position and bony quality of the patient at the time of injury, axial violent transmission may cause different types of die-punch fracture at the intermediate column of the distal radius and different types of mild radial column fractures as well. As our new classification may well characterize the site and morphology of DPFDR, it has high consistency to guide surgical treatment and prognosis judgment.