桡骨远端楔形截骨术与植骨加压螺丝钉固定术治疗腕舟状骨骨折不愈合的疗效比较

目的:比较桡骨远端楔形截骨术与植骨加压螺钉内固定术治疗腕舟状骨骨折不愈合的疗效.方法:分为两组,A组为2003年月3月到2006年12月应用桡骨远端楔形截骨术治疗腕舟状骨骨折不愈合33例,B组为2007年1月到2010年6月,应用植骨加压螺钉内固定术治疗腕舟状骨骨折不愈合23例.术后随访6个月-5年,随访检查包括X线检查骨折愈合情况及腕关节疼痛程度、腕关节活动度、握力.结果:A组:X线检查腕舟状骨均愈合,骨折线消失;桡骨远端截骨处完全愈合,桡骨远端关节面尺偏角变平,近乎平面.腕疼痛值静息时为1.1,用力后为2.3;屈伸活动度为122度(健侧126度),尺桡偏为49度(健侧57度);平均握力为38kg(健侧40Kg).B组,X线片检查23例中有3例仍骨折不愈合,骨折愈合率87%,骨折愈合者腕疼痛值静息时为1.2,用力后为2.4;屈伸活动度为120度(健侧126度),尺桡偏为50度(健侧57度);平均握力为36Kg(健侧40Kg).结论:通过对两种术式治疗腕舟状骨骨折不愈合的疗效比较,桡骨远端楔形截骨术较植骨加压螺钉内固定术愈合率高,使腕关节的绝大部分功能得到保存,是治疗腕舟状骨不愈合的有效方法.两种方法骨折愈合后对腕关节活动度、疼痛程度、握力的影响无显著差异.     

可吸收螺钉内固定结合创必复治疗陈旧性舟骨骨折

目的 探讨应用可吸收螺钉(grand fix)内固定结合bFGF生物蛋白海绵(创必复)治疗陈旧性舟骨骨折及骨不连的临床疗效及安全性.方法 对9例陈旧性舟骨骨折按Herbert分型:Ⅲ型6例,Ⅳa型2例,Ⅳb型1例.取桡背侧切口,应用可吸收螺钉内固定,骨折端填塞、覆盖bFGF生物蛋白海绵.结果 9例术后随访时间平均为7.3个月.其中8例舟骨骨折全部愈合,腕关节活动范围:掌屈45.～55.,背伸40°～50°,桡偏20°～25°,尺偏25°～35°;腕部握力平均恢复至健侧的88％.1例舟骨不愈合,骨折端硬化,持重物后疼痛、无力,腕关节活动范围:掌屈20°,背伸25°,桡偏10°,尺偏15°.术后全部患腕均无过敏反应及感染发生.结论 可吸收螺钌内固定结合bFGF生物蛋白海绵治疗陈旧性舟骨骨折,具有生物相容性好、固定可靠、安全性高等优点,可促进舟骨骨折愈合.     

可吸收螺钉联合腕关节成形术治疗舟状骨骨折

目的 评价可吸收螺钉联合腕关节成形术治疗舟状骨骨折的临床效果.方法 采用可吸收螺钉联合腕关节成形术治疗舟状骨骨折32例.按Herbert分型:B4型3例,B1型5例,B3型6例,B2型18例.结果 平均随访18个月(10～26个月),1例失访.疗效按MMWSS评分:优9例,良14例,一般5例,差3例,优良率达74.2%,1例骨折不愈合.结论 可吸收螺钉联合腕关节成形术可作为治疗腕舟状骨骨折的一种可靠方法 ,又可以避免二次手术.     

双加压螺钉内固定治疗腕舟状骨骨折

目的总结双加压螺钉治疗腕舟状骨骨折的临床疗效。方法自2006年1月至2009年6月共收治11例腕舟状骨骨折,按Herbert分型均为Ⅱ型,按术前手术方案选择不同入路,复位后均行双加压螺钉内固定。结果9例获随访,时间2个月～1年6个月,8例腕关节功能恢复良好,其中7例腕关节桡偏、尺偏、掌曲、背伸活动与健侧相比无明显差别,1例稍差于健侧。1例在活动时偶有酸痛感,其余均无明显疼痛等不适。X线检查8例骨折已愈合,1例发现在术后4个月时出现骨断端骨吸收现象,愈合缓慢。结论腕舟状骨骨折早期诊断是决定其治疗效果重要因素之一,手术适应证的掌握及牢固固定是又一重要因素。双加压螺钉已成为首选内固定。微创手术发展是新选择及趋势,具有更大优势。     

不同筋膜血管蒂骨瓣植入治疗舟状骨陈旧性骨折

目的介绍利用不同筋膜血管蒂桡骨茎突骨瓣植入治疗陈旧性腕舟状骨骨折的疗效。方法2002年9月-2010年5月,采用以桡动脉返支为蒂的骨瓣,或以骨间背动脉桡侧终末支的筋膜蒂骨瓣植入结合内固定治疗腕舟状骨陈旧性骨折41例。结果38例经6～27个月（平均19．3个月）的随访,X线片显示腕舟骨骨折均在术后4～6个月获得骨性愈合,愈合率达100％。腕关节活动度为4例腕掌屈60°背伸50°34例腕掌屈达70°-80°．背伸45°-55°。腕关节活动时无疼痛。腕关节功能按Krimmer评分表测定：总体疗效为优29例,良9例。结论采用带不同血管蒂桡骨茎突骨瓣植入治疗舟状骨陈旧性骨折疗效确切。     

微型哈勃螺钉内固定治疗腕舟状骨骨折疗效分析

目的 总结腕舟状骨骨折采用微型哈勃螺钉内固定手术治疗结果并加以分析.方法 对腕舟状骨骨折10例采用腕桡侧切口切开复位、微型哈勃螺钉内固定.评价骨折愈合情况和腕关节功能.结果 骨折全部愈合,骨折愈合时间2.2～3.9个月,平均3.0个月.腕关节功能得到明显改善.结论 腕舟状骨骨折采用微型哈勃螺钉内固定手术治疗,易于骨折愈合、疗效确切.     

可吸收棒内固定治疗陈旧性腕舟骨骨折

目的探讨可吸收棒治疗陈旧性腕舟骨骨折的手术疗效。方法对17例陈旧性腕舟骨骨折,按Herbert分类:D1型4例,D2型11例,D3型2例,采用骨折切开复位自体松质骨植骨,可吸收棒内固定术。结果17例获得4~26个月随访,平均9个月。术后伤口均Ⅰ期愈合,骨折愈合时间8~19周,平均13周。腕关节活动范围掌屈[(49.5±8.5)°,x-±s,下同],(达健侧78.3%);背伸(41.5±4.5)°,(达健侧70.5%);桡偏(16.5±2.5)°,(达健侧57.1%);尺偏(24.5±5.5)°,(达健侧60.3%)。15例腕关节活动时无疼痛。2例有疼痛。腕部握力(24.7±3.1)kg,(达健侧83.2%)。术后X线片示17例均未发生腕骨性关节炎及舟骨缺血性坏死。结论可吸收棒治疗陈旧性舟骨骨折手术操作简单,固定牢靠,可缩短骨折愈合时间及提高骨折愈合率,是治疗陈旧性舟骨骨折的一种有效的手术方法。     

可吸收螺钉治疗HerbertB型舟状骨骨折

目的讨论用可吸收螺钉治疗HerbertB型舟状骨骨折的临床疗效。方法随机抽取本院2004年1月至2009年5月Her-bertB型舟状骨骨折患者16例,采用切开复位,2．0mm可吸收螺钉固定,术后早期进行腕关节的屈伸及前臂的旋转活动,定期随访评估腕关节功能。结果16例骨折均获I期愈合,腕关节功能恢复满意。结论用可吸收螺钉治疗HerbertB型舟状骨骨折．无需二次手术取出内固定,患者能早期进行功能锻炼,并获得良好疗效。     

经皮微创加压螺钉内固定治疗腕舟状骨骨折

目的探讨采用经皮微创加压螺钉内固定治疗腕舟状骨骨折的疗效。方法采用经皮微创加压螺钉内固定治疗腕舟状骨骨折9例。结果本组获随访3~6个月,骨折均获得愈合,骨折平均愈合时间为8周。患者于功能活动时均无腕部疼痛,腕关节活动度均达到对侧的90%以上。结论采用微创方法置入加压螺钉内固定治疗新鲜腕舟状骨骨折,近期疗效满意。     

空心螺钉不同置入方法治疗腕舟状骨骨折疗效比较

[目的]评价腕掌侧入路加压螺钉由腕舟状骨近极向远极固定和由远极向近极固定对腕舟状骨骨折患者骨折预后及功能恢复的临床疗效。[方法]采用腕掌侧入路加压螺钉治疗48例腕舟状骨骨折患者,均为跌伤,按手术方法不同分为两组,近极向远极组:由腕舟状骨近极向远极固定(23例),远极向近极组:由腕舟状骨远极向近极固定(25例)。随访并比较两组间骨折愈合时间、愈合率及腕关节功能Cooney评分和DASH问卷调查表结果。[结果]近极向远极组有20例获得骨性愈合,愈合率86.9%,平均愈合时间(10.52±2.85)周,远极向近极组有19例获得骨性愈合,愈合率76%,平均愈合时间(14.31±1.98)周,两组比较差异有统计学意义(P<0.05)。Cooney评分结果:近极向远极组:优11例,良7例,中1例,差1例,优良率78.26%;远极向近极组:优9例,良4例,中2例,差4例,优良率52%,两组比较差异有统计学意义(P<0.05)。DASH问卷调查表评分:近极向远极组平均值(7.32±1.28)分,低于远极向近极组的(9.58±3.24)分,差异有统计学意义(P<0.05)。[结论]腕掌侧入路加压螺钉采用由近极向远极固定的方法能够较好地保护腕舟状骨血供,比由远极向近极固定更有效地促进骨折愈合及术后腕关节功能的恢复。     

Kinematics of the midcarpal and radiocarpal joint in flexion and extension: an in vitro study

PURPOSE: To apply carpal kinematic analysis using noninvasive medical imaging to investigate the midcarpal and radiocarpal contributions to wrist flexion and extension in a quasidynamic in vitro model. METHODS: Eight fresh-frozen cadaver wrists were scanned with computed tomography in neutral, full flexion, and full extension. Body-mass-based local coordinate systems were used to track motion of the capitate, lunate, and scaphoid with the radius as a fixed reference. Helical axis motion parameters and Euler angles were calculated for flexion and extension. RESULTS: Minimal out-of-plane carpal motion was noted with the exception of small amounts of ulnar deviation and supination in flexion. Overall wrist flexion was 68 degrees +/- 12 degrees and extension was 50 degrees +/- 12 degrees. In flexion, 75% of wrist motion occurred at the radioscaphoid joint, and 50% occurred at the radiolunate joint. In extension, 92% of wrist motion occurred at the radioscaphoid joint, and 52% occurred at the radiolunate joint. Midcarpal flexion/extension between the capitate and scaphoid was 0 degrees +/- 5 degrees in extension and 10 degrees +/- 13 degrees in flexion. Midcarpal flexion/extension between the capitate and lunate was larger, with 15 degrees +/- 11 degrees in extension and 22 degrees +/- 19 degrees in flexion. CONCLUSIONS: The capitate and scaphoid tend to move together. This results in greater flexion/extension for the scaphoid than the lunate at the radiocarpal joint. The lunate has greater midcarpal motion between it and the capitate than the scaphoid does with the capitate. The engagement between the scaphoid and capitate is particularly evident during wrist extension. Out-of-plane motion was primarily ulnar deviation at the radiocarpal joint during flexion. These results are clinically useful in understanding the consequences of isolated fusions in the treatment of wrist instability.     

双空心螺钉内固定术治疗Herbert B型腕舟骨骨折

目的探讨采用2枚微型空心螺钉内固定术治疗腕舟骨骨折的临床疗效。方法对13例腕舟骨骨折采用双空心螺钉行切开复位内固定术,均选择掌侧入路,早期功能锻炼。术后评估腕部疼痛、腕关节活动度、手部握力及骨折愈合情况,并用Krimmer评分法评估疗效。结果 13例均获随访,随访时间12～32个月,平均15个月。骨折均一期愈合,治愈率为100%。愈合时间为4～9周,平均6周。11例活动度与健侧相同,无疼痛等不适感觉。2例桡偏和掌屈欠5°～10°,腕关节掌屈时感轻度疼痛,无其他并发症。按Krimmer评分法评估总体疗效:优11例,良2例。结论采用双空心螺钉切开复位内固定治疗腕舟骨骨折,愈合率高,功能恢复好,是治疗腕舟骨骨折的一种较好方法。     

Capitate-based kinematics of the midcarpal joint during wrist radioulnar deviation: an in vivo three-dimensional motion analysis

PURPOSE: The purpose of this study was to obtain qualitative and quantitative information regarding in vivo 3-dimensional (3D) kinematics of the midcarpal joint during wrist radioulnar deviation (RUD). METHODS: We studied the in vivo kinematics of the midcarpal joint during wrist RUD in the right wrists of 10 volunteers by using a technology without radioactive exposure. The magnetic resonance images were acquired during RUD. The capitate was registered with the scaphoid, the lunate, and the triquetrum by using a volume registration technique. Animations of the relative motions of the midcarpal joint were created and accurate estimates of the relative orientations of the bones and axes of rotation (AORs) of each motion were obtained. RESULTS: The scaphoid, lunate, and triquetrum motions relative to the capitate during RUD were found to be similar, describing a rotational motion around the axis obliquely penetrating the head of the capitate in almost a radial extension/ulnoflexion plane of motion of the wrist. The AORs of the scaphoid, the lunate, and the triquetrum were located closely in space. In the axial plane the AORs of the scaphoid, lunate, and triquetrum formed a radially and palmarly opening angle of 43 degrees +/- 7 degrees, 41 degrees +/- 11 degrees, and 42 degrees +/- 14 degrees with the wrist flexion/extension axis, respectively. CONCLUSIONS: This study reports the in vivo 3D measurements of midcarpal motion relative to the capitate. Isolated midcarpal motion during RUD could be approximated to be a rotation in a plane of a radiodorsal/ulnopalmar rotation of the wrist, which may coincide with a motion plane of one of the most essential human wrist motions, known as the dart-throwing motion.     

Screw fixation of scaphoid fractures: a biomechanical assessment of screw length and screw augmentation

PURPOSE: To assess the biomechanical stability relative to screw length and K-wire augmentation in scaphoid fracture fixation using a flexibility testing protocol and cadaver scaphoids whose soft tissue attachments remained undisturbed. Our hypothesis was 2-fold: increasing screw length and augmenting fixation with a K-wire would improve fracture fragment stability, individually and in combination. METHODS: Flexion and extension loading applied through wrist tendons was performed on 10 cadaveric wrists after volar wedge scaphoid osteotomy and internal fixation. Each wrist participated in 3 experimental groups: short screw, long screw, and long screw augmented with a K-wire transfixing the distal pole to the capitate. Interfragmentary displacements were measured. RESULTS: Analysis of variance showed significantly less fracture fragment motion with longer screws than with short screws in 4 of the 6 displacement axes. The flexion/extension axis rotations for the short, long, and augmented long-screw groups were 8.2 degrees +/- 4.8 degrees, 3.9 degrees +/- 1.6 degrees, and 1.8 degrees +/- 1.3 degrees, respectively. Although K-wire augmentation reduced displacement of the fracture fragments it did not decrease interfragmentary motion significantly when compared with the long-screw group. CONCLUSIONS: Under physiologically applied loading of cadaveric wrists with unstable scaphoid waist fractures the long screw provided significantly greater stability than the short screw. Although K-wire augmentation in the long-screw group did improve stability the improvements were not significant. Based in part on the biomechanical data from this study it is our recommendation that the optimally placed screw for scaphoid fracture fixation stability is a long screw positioned down the central axis of the scaphoid deep into subchondral bone.     

Repair of flexor carpi radialis tendon laceration at the wrist in a professional ice hockey player

The flexor carpi radialis is a wrist flexor and radial deviator with half the relative strength of flexor carpi ulnaris. In the majority of patients, the flexor carpi radialis tendon is expendable and is routinely used for various reconstructive procedures about the hand and wrist. Isolated flexor carpi radialis lacerations at the wrist are rare. Flexor carpi radialis tendon ruptures, which have been reported in association with distal radius fractures, longstanding osteoarthritis, and percutaneous treatment of scaphoid fractures, are usually treated non-operatively. We report a case of a traumatic laceration of the flexor carpi radialis tendon at the wrist in a professional ice hockey player. Surgical repair and rehabilitation using established principles for intrasynovial flexor tendon repair allowed return to sport at the professional level in 2 months.Tension-free core suture repair was performed with a modified-Kessler, 4-strand repair using a double-stranded 4-0 Supramid suture. A running epitendinous suture was then placed around the circumference of the tendon with 6-0 Prolene. Immobilization of the wrist in 20° of flexion was maintained for 2 weeks. Full active and passive digital motion was allowed immediately postoperatively and continued throughout the rehabilitation. Therapy was initiated at 2 weeks postoperatively with full passive wrist flexion and passive wrist extension to a dorsal block of 20°. At 4 weeks postoperatively, a dorsal splint was fabricated to keep the wrist in neutral. At this time, active extension to a dorsal block of zero and full passive flexion was allowed. Active wrist flexion without resistance was begun at 6 weeks, and full strengthening was allowed at 8 weeks postoperatively. The patient returned to sport at the professional level shortly thereafter. At latest follow-up, the patient has been able to fully participate in professional ice hockey without pain or functional limitation.     

Biomechanical changes of the wrist flexor and extensor tendons following loss of scaphoid integrity

Loss of integrity of the scaphoid may change the motion center of the entire carpus, and deformities from scaphoid fractures may alter the location of motor tendons of the wrist, thus altering their biomechanics. The goal of this study was to clarify biomechanical changes in these tendons following loss of scaphoid integrity. Excursions and moment arms of the principal flexor and extensor tendons of the wrist were investigated in seven cadaveric upper extremities in intact wrists after simulation of scaphoid waist fracture and after removal of the proximal scaphoid. Excursions of the flexor carpi radialis and ulnaris extensor carpi radialis longus and brevis, and extensor carpi ulnaris tendons were measured with rotary potentiometers during wrist flexion-extension and radioulnar deviation. Simultaneously, wrist joint angulation was recorded. Moment arms of the tendons were derived from tendon excursions and joint motion. After scaphoid fracture, the moment arms of the flexor carpi radialis and extensor carpi ulnaris tendons increased significantly during wrist flexion-extension, whereas the moment arms of the extensor carpi radialis longus and brevis tendons decreased significantly. After proximal scaphoid excision, the moment arms of the extensor carpi radialis longus and brevis tendons again decreased significantly during wrist flexion-extension. The moment arms of the flexor carpi radialis and extensor carpi radialis brevis tendons increased significantly during radioulnar deviation, whereas those of the wrist motors on the ulnar side decreased. These findings indicate the importance of the integrity of the scaphoid in maintaining normal biomechanics of motor tendons of the wrist. An increase in the moment arm of the radial wrist flexor along with a decrease in moment arms of the radial extensors constitutes an etiology for persistent angulation of the scaphoid and the hump-back deformity. In addition, disturbing the biomechanics of the wrist motor tendons predisposes the carpal joints to abnormal loading, potentially contributing to the development of carpal joint degeneration.     

Open reduction and internal fixation of acute displaced scaphoid waist fractures

Fourteen consecutive patients with acute displaced scaphoid waist fractures were treated with open reduction and internal fixation. The operative technique consisted of anatomic reduction of the displaced scaphoid waist fracture, correction of carpal instability, radial bone grafting for comminution, and internal fixation with K-wires or Herbert screw. The patients were evaluated an average of 26 months (range, 4-48 months) after surgery. Thirteen of the 14 (93%) fractures united. The average time to union was 11.5 weeks (range, 8-20 weeks). Fracture union was confirmed with trispiral tomography. Final radiographic assessment consistently revealed a healed scaphoid fracture, restored intrascaphoid alignment, and no evidence of carpal instability. All patients regained functional wrist range of motion (wrist extension, 57 degrees; wrist flexion, 52 degrees ) and grip strength. Open reduction and internal fixation of acute displaced scaphoid waist fractures restores scaphoid alignment and leads to predictable union. Early operative intervention avoids malunion and carpal instability that often occurs with closed management of these complex fractures.     

Acute fractures of the scaphoid. Treatment by cast immobilisation with the wrist in flexion or extension?

Acute fractures of the scaphoid were randomly allocated for conservative treatment in a Colles'-type plaster cast with the wrist immobilised in either 20 degrees flexion or 20 degrees extension. The position of the wrist did not influence the rate of union of the fracture (89%) but when reviewed after six months the wrists which had been immobilised in flexion had a greater restriction of extension. We recommend that acute fractures of the scaphoid should be treated in a Colles'-type cast with the wrist in slight extension.     

Trans-scaphoid perilunate fracture dislocations: results of screw fixation of the scaphoid and lunotriquetral repair with a dorsal approach

PURPOSE: To review the clinical and radiographic outcome of dorsal trans-scaphoid perilunate fracture-dislocations treated with screw fixation of the scaphoid and repair of the lunotriquetral ligament with bone anchors. METHODS: Twenty-five patients treated over an 11-year period for dorsal trans-scaphoid perilunate fracture-dislocations were reviewed retrospectively at a mean of 44.3 months. The mean age of the patients was 28.6 years, and 22 patients were men. Delay to surgery was 3.5 days. Five scaphoids had bone grafting from the distal radius. Six patients developed carpal tunnel syndrome requiring release. The functional outcome was determined by comparing the range of motion of the injured extremity with the uninjured extremity, grip strength, ability to return to pre-injury employment, and overall patient satisfaction. Radiographic evaluation comprised time to scaphoid union, any changes in the lunotriquetral interval, development of a volar intercalated segmental instability pattern, and any development of arthritis over time. RESULTS: Total range of motion achieved was 91% of the uninjured wrist and grip strength was 80%. Average extension was 54 degrees with an average flexion of 60 degrees . Ulnar deviation was 23 degrees with radial deviation averaging 18 degrees . The average supination was 76 degrees and the average pronation was 76 degrees . All scaphoids united primarily. The average time to union of the scaphoid was 16 weeks. For those scaphoids with bone grafting the union time was an average of 18.4 weeks. The average postreduction lunotriquetral gap was 1.8 +/- 0.4 mm. The average lunotriquetral gap at the last follow-up evaluation was 1.9 +/- 0.6 mm. None of the patients developed a volar intercalated segmental instability deformity. All but 2 patients returned to their pre-injury occupation. All patients, however, returned to some type of employment. Complications included 1 superficial pin track infection that resolved with removal of the pin and a short course of oral antibiotics. CONCLUSIONS: A dorsal approach to the wrist provides adequate exposure for reduction of carpal bones, internal fixation of the scaphoid, and lunotriquetral repair. Although perilunate fracture-dislocations are challenging problems to treat, all of the patients had acceptable pain relief and achieved sufficient range of motion and strength to return to gainful employment.     

Russe手术治疗陈旧性腕舟骨骨折

目的　评价应用 Russe手术治疗陈旧性腕舟骨骨折的临床效果。　方法　对 1987年 1月～ 1999年2月手术治疗的 11例患者进行随访、评定。其中男 9例 ,女 2例 ,年龄 19～ 2 4岁。优势手 10例。术前病程 3～ 10个月 ,均有外伤史、腕痛、活动受限及握力减弱。X线片示腕舟骨腰部横形骨折 10例 ,近 1/ 3骨折 1例 ;5例呈囊性变和硬化 ,2例骨折近侧骨块密度增高。　结果　 11例获 15个月～ 9年随访 ,平均 5年 7个月。骨折均愈合 ,愈合时间为术后 2～ 5个月 ,平均 3.1个月 ,腕关节掌屈、背伸、桡偏和尺偏的平均活动度分别为 4 1.2°、4 0 .5°、8.7°和 15 .4°,分别达到健侧的6 8.3%、6 7.5 %、4 3.5 %和 5 1.3%。患侧握力平均达到健侧的 82 .9% ,腕部疼痛消失。　结论　 Russe手术是治疗陈旧性腕舟骨骨折的一种简便有效的方法。