背尺侧骨块累及月骨窝关节面1/8至1/3的AO分型C型桡骨远端骨折的内固定治疗

Internal fixation treatment of AO-C type distal radius fractures accompanied with a dorsoulnar fragment involving 1/8 to 1/3 of the articular surface of the lunate facet

目的探讨内固定治疗背尺侧骨块累及月骨窝关节面1/8至1/3的AO分型C型桡骨远端骨折的临床疗效。方法回顾性分析2017年7月至2022年7月同济大学附属同济医院收治的背尺侧骨块累及月骨窝关节面1/8至1/3的C型桡骨远端骨患者55例,根据手术方式分为三组。掌侧钢板组(单纯采用掌侧锁定钢板治疗)22例,男11例、女11例,年龄(56.7±10.1)岁,C1型10例、C2型7例、C3型5例;掌侧钢板+背侧钢板组(采用掌侧锁定钢板联合背侧钢板治疗)15例,男6例、女9例,年龄(55.7±8.1)岁,C1型4例、C2型5例、C3型6例;掌侧钢板+背侧螺钉组(采用掌侧锁定钢板联合背侧螺钉治疗)18例,男8例、女10例,年龄(53.5±11.6)岁,C1型7例、C2型5例、C3型6例。比较三组患者手术时间、术后影像学指标、腕关节活动度、上肢功能障碍(disability of arm,shoulder and hand,DASH)评分、视觉模拟评分(visual analogue scale,VAS)以及并发症情况。结果所有患者手术均顺利完成,随访时间(14.9±2.2)个月(范围12~18个月);骨折均愈合,愈合时间为(12.4±2.3)周(范围9~16周)。掌侧钢板组、掌侧钢板+背侧钢板组、掌侧钢板+背侧螺钉组患者手术时间分别为(54.3±7.6)min、(70.7±5.9)min、(65.8±7.1)min,掌侧钢板组患者手术时间更少(F=27.04,P<0.001)。三组患者术后CT矢状面、冠状面、横断面背尺侧骨块残留移位距离分别为[(1.3±0.8)mm、(0.6±0.4)mm、(0.7±0.4)mm]、[(1.1±0.8)mm、(0.6±0.4)mm、(0.6±0.6)mm]、[(1.4±0.8)mm、(0.7±0.4)mm、(0.7±0.5)mm],掌背侧联合内固定两组的移位距离小于掌侧钢板组(P<0.05)。术后3个月三组患者腕关节掌屈活动度分别为44.2°±4.6°、47.7°±5.9°、48.8°±5.1°,背伸活动度分别为39.8°±6.2°、44.3°±4.6°、44.7°±5.1°,腕关节DASH评分分别为(23.0±4.2)分、(20.1±4.1)分、(19.4±3.0)分,VAS评分分别为(2.3±1.2)分、(1.6±1.3)分、(1.3±1.0)分。掌侧钢板+背侧钢板组患者腕关节掌屈和背伸活动度、DASH评分优于掌侧钢板组(P<0.05);掌侧钢板+背侧螺钉组患者的腕关节掌屈和背伸活动度、DASH评分及VAS评分均优于掌侧钢板组(P<0.05)。术后12个月三组患者腕关节活动度、VAS及DASH评分的差异均无统计学意义(P>0.05)。掌侧钢板组2例患者出现复位丢失、3例出现腕关节慢性疼痛,掌侧钢板+背侧钢板组1例患者出现背侧肌腱激惹,掌侧钢板+背侧螺钉组无明显并发症发生。结论对背尺侧骨块累及月骨窝关节面1/8至1/3的C型桡骨远端骨折采用掌背侧联合内固定可提高背尺侧骨块的复位精度及稳定性,有助于术后腕关节功能的早期康复,联合背侧螺钉与背侧钢板内固定疗效相当,但螺钉内固定并发症较少。

Objective To explore the clinical outcome of internal fixation in the treatment of AO C-type distal radius fracture accompanied with dorsoulnar fragment involving 1/8 to 1/3 of the articular surface of the lunate facet.Methods A total of 55 patients of AO C-type distal radius fracture accompanied with dorsoulnar fragment involving 1/8 to 1/3 of the articular surface of the lunate facet from July 2017 to July 2022 in Tongji Hospital Affiliated to Tongji University were retrospectively analyzed.In the volar plate group(volar locking plate treatment alone),there were 22 cases,11 males and 11 females,aged 56.7±10.1 years,10 C1 type,7 C2 type and 5 C3 type.There were 15 patients in the volar plate+dorsal plate group(treated with volar locking plate combined with dorsal plate),including 6 males and 9 females,aged 55.7±8.1 years old,4 C1 type,5 C2 type and 6 C3 type.In the volar plate+dorsal screw group(treated with volar locking plate combined with dorsal screw),there were 18 cases,8 males and 10 females,aged 53.5±11.6 years,7 cases of C1 type,5 cases of C2 type,and 6 cases of C3 type.The operation time,postoperative radiographic indicators,wrist range of motion(ROM),disability of arm,shoulder and hand(DASH)score,visual analogue scale(VAS)and postoperative complications were evaluated and compared between the three groups.Results All operations were successfully completed.Patients were followed up for 14.9±2.2 months(range,12-18 months),and the fracture healing time was 12.4±2.3 weeks(range,9-16 weeks).The operative time of patients in the volar plate group,volar plate+dorsal plate group and volar plate+dorsal screw group was 54.3±7.6 min,70.7±5.9 min and 65.8±7.1 min,respectively.Patients in the volar plate group had less operative time(F=27.04,P<0.001).The residual displacement of the dorsoulnar fragment in sagittal,coronal,and axial CT scans in the three groups were(1.3±0.8 mm,0.6±0.4 mm,0.7±0.4 mm),(1.1±0.8 mm,0.6±0.4 mm,0.6±0.6 mm),(1.4±0.8 mm,0.7±0.4 mm,0.7±0.5 mm).The displacement of the dorsoulnar fragment of the two groups of combined volar and dorsal internal fixation was smaller than that of the volar plate group(P<0.05).The ROM of wrist flexion of the three groups at 3 months after operation were 44.2°±4.6°,47.7°±5.9°,48.8°±5.1°,the ROM of wrist extension were 39.8°±6.2°,44.3°±4.6°,44.7°±5.1°,the wrist DASH scores were 23.0±4.2,20.1±4.1 and 19.4±3.0,and the VAS were 2.3±1.2,1.6±1.3 and 1.3±1.0,respectively.The ROM of wrist flexion and extension and DASH score in volar plate+dorsal plate group were better than those in volar plate group(P<0.05).The ROM of wrist flexion and extension,DASH score and VAS in the volar plate+dorsal screw group were better than those in the volar plate group(P<0.05).There were no significant differences in terms of the wrist ROM,DASH score and VAS at 12 months after operation among the three groups(P>0.05).There were 2 patients in the volar plate group with reduction loss,3 patients with wrist chronic pain;1 patient in the volar plate combined with dorsal plate group with dorsal tendon irritation,and no complications in the volar plate combined with dorsal screw group.Conclusion For AO C-type distal radius fractures accompanied with a dorsoulnar fragment involving 1/8 to 1/3 of the articular surface of the lunate facet,the use of combined volar and dorsal internal fixation can improve the reduction accuracy and stability of the dorsoulnar fragment,and contribute to the early rehabilitation of postoperative wrist joint function.The effect of combined dorsal screw is comparable to that of dorsal plate internal fixation,but the complications of screw internal fixation are less.