改良腕管位透视在掌侧钢板内固定治疗桡骨远端骨折中的应用

Application of improved carpal shoot through view in volar plate internal fixation of distal radius fractures

目的 探讨改良腕管位透视(improved carpal shoot through view,ICSTV)在掌侧钢板内固定治疗桡骨远端骨折术中的应用价值。方法 回顾分析2020年1月—2023年1月收治且符合选择标准的67例桡骨远端骨折患者临床资料。其中男30例,女37例;年龄18~75岁,平均53.6岁。国际内固定研究协会/美国骨创伤协会(AO/OTA)分型为B型25例,C型42例。受伤至手术时间2~6 d,平均3.8 d。术中行双皮质钻孔,植入螺钉长度较测深尺测量值短1~2 mm;掌侧解剖锁定钢板固定完毕后行标准正侧位(anteroposterior and lateral,AAL)透视和ICSTV透视,若检测出桡骨远端背侧皮质穿出给予更换短钉再次行ICSTV透视,至无螺钉穿出为止;比较AAL透视和ICSTV透视螺钉穿出背侧皮质的检出率。术后行CT检查确认有无螺钉穿出背侧皮质。结果 术中AAL透视发现4例患者(6.0%)5枚螺钉穿出背侧皮质,ICSTV透视发现包含上述4例患者在内的15例患者(22.4%)19枚螺钉穿出背侧皮质,两种透视方法检出率比较差异有统计学意义[OR=0.267(0.084,0.845),P=0.018];15例患者术中均更换为短钉。同时ICSTV透视检测出2例(3.0%)2枚螺钉穿入下尺桡关节,并且在AAL透视中未发现,均给予调整螺钉方向并更换螺钉。所有患者术后3 d内复查腕关节CT均未发现螺钉穿出背侧皮质或穿入下尺桡关节。67例患者均获随访,随访时间6~18个月,平均11.3个月。2例术后3个月发生伸肌腱激惹症状,所有患者随访期间均无伸肌腱断裂发生。骨折均愈合良好,愈合时间8~13周,平均10.8周;无内固定物松动、骨折移位等并发症发生。末次随访时Gartland-Werley评分为0~15分,平均5.6分。结论ICSTV透视可以有效检测出AAL透视无法显示的隐匿性桡骨远端螺钉穿出背侧皮质。

Objective To explore the application of improved carpal shoot through view(ICSTV)method in the treatment of distal radius fractures with volar plate internal fixation.Methods The clinical data of 67 patients with distal radius fractures who met the selection criteria between January 2020 and January 2023 was retrospectively analyzed.There were 30 males and 37 females with an average age of 53.6 years(range,18-75 years).According to the AO/Orthopaedic Trauma Association(AO/OTA)classification,there were 25 cases of type B and 42 cases of type C.The time from injury to operation ranged from 2 to 6 days,with an average of 3.8 days.During the operation,bilateral cortical drilling was performed,and the length of the implanted screw was 1-2 mm shorter than that measured by the depth ruler.Standard anteroposterior and lateral(AAL)fluoroscopy and ICSTV fluoroscopy were performed after volar anatomic locking plate fixation,respectively.If the dorsal cortex of the distal radius was detected to be penetrated,the short screw was replaced and ICSTV fluoroscopy was performed again until no screw was penetrated.The detection rate of dorsal cortical screw penetration was compared between AAL fluoroscopy and ICSTV fluoroscopy.Postoperative CT scan was performed to confirm the presence or absence of dorsal cortical screw penetration.Results Intraoperative AAL fluoroscopy found 5 screws penetrating the dorsal cortex in 4 patients(6.0%),and ICSTV fluoroscopy found 19 screws penetrating the dorsal cortex in 15 patients(22.4%)including the above 4 patients,with a significant difference in the detection rate between the two fluoroscopy methods[OR=0.267(0.084,0.845),P=0.018];15 patients were replaced with short screws during operation.At the same time,ICSTV fluoroscopy detected 2 screws penetrating into the distal radioulnar joint in 2 cases(3.0%),which could not be found in AAL fluoroscopy,and the direction of the screws was adjusted and replaced.All patients were reexamined by wrist CT within 3 days after operation,and no dorsal cortical screw penetration or screw penetration into the distal radioulnar joint was found.All the 67 patients were followed up 6-18 months,with an average of 11.3 months.Extensor tendon irritation occurred in 2 patients at 3 months after operation,and no extensor tendon rupture occurred in all patients during follow-up.All fractures healed well,and the healing time was 8-13 weeks,with an average of 10.8 weeks.There was no complication such as internal fixation loosening or fracture displacement.The Gartland-Werley score at last follow-up ranged from 0 to 15,with an average of 5.6.Conclusion ICSTV fluoroscopy can effectively detect occult dorsal cortical screw penetration of the distal radius that can not be revealed by AAL fluoroscopy.