本文選題：骨折 + 橈骨遠端��； 參考：《天津醫(yī)科大學》2017年博士論文

【摘要】：研究背景:橈骨遠端骨折是常見的腕部損傷,其發(fā)生率呈現(xiàn)出逐年增長的趨勢。橈骨遠端骨折病人的發(fā)生率每年大約為26/10000,占到所有前臂骨折患者的72%,占所有上肢骨折患者的8~17%,橈骨遠端骨折病人占所有急診患者的1/6。橈骨遠端骨折患者呈現(xiàn)出雙峰特征,即青年患者和老年患者。目前,切開復位鋼板內固定手術是治療橈骨遠端骨折一項可靠的手術技術。但究竟是掌側鋼板固定還是背側鋼板固定更恰當,仍存在爭論。在臨床上,橈骨遠端骨折掌側鋼板固定非常流行,背側入路鋼板固定則相對較少。分析發(fā)生此現(xiàn)象的原因,可能受到傳統(tǒng)觀點影響,認為掌側鋼板內固定術后并發(fā)癥發(fā)生率相對較少,背側鋼板內固定術后并發(fā)癥發(fā)生率相對較多。隨著最新研制的超薄低切跡背側鋼板的出現(xiàn),背側鋼板固定出現(xiàn)了更少的術后并發(fā)癥。但在臨床工作中我們發(fā)現(xiàn),掌側入路鋼板固定并不是萬能的,掌側鋼板固定在某些特定骨折類型上的應用遭遇了一些內固定失敗,骨折再移位甚至腕關節(jié)脫位等嚴重后果。這引起了我們的反思。研究目的:在臨床實踐中我們發(fā)現(xiàn),橈骨遠端骨折根據(jù)受傷當時的損傷機制,骨折形態(tài)表現(xiàn)出其各自特點。因此我們假設初始骨折移位方向能夠決定手術治療策略,并且恰當應用此理念能夠牢固固定移位骨折塊并能相應減少術后內固定失敗的發(fā)生率。因此我院創(chuàng)傷科進行了一項前瞻性的實驗研究來進行佐證。并且針對大家對背側鋼板內固定的偏見,我們通過查閱國內外相關文獻,利用Meta分析比較掌、背側鋼板內固定治療成人橈骨遠端骨折術后并發(fā)癥發(fā)生率的差異,為探究治療橈骨遠端骨折的最優(yōu)治療選擇提供臨床參考依據(jù)。研究方法:總結我院創(chuàng)傷科自2012年10月至2015年10月之間納入此項前瞻性研究有針對性手術治療的橈骨遠端骨折病例34例。依據(jù)橈骨遠端骨折初始掌側移位趨勢納入切開復位掌側鋼板內固定組(15例),背側移位趨勢則納入背側鋼板內固定組(19例)。治療主要觀察指標:腕關節(jié)功能結果,影像學結果,DASH評分及術后并發(fā)癥等。對于meta分析研究,我們在無語種限制的條件下檢索在2017年1月25日之前在國內外公開發(fā)表的有關橈骨遠端骨折使用掌側入路鋼板固定和背側入路鋼板固定術后相關并發(fā)癥對比的臨床對照試驗。使用Rev Man 5軟件合并相關數(shù)據(jù),對各種術后并發(fā)癥的發(fā)生率等數(shù)據(jù)進行統(tǒng)計分析。研究結果:本臨床研究共納入橈骨遠端骨折患者34例,男16例,女18例;年齡19~62歲,平均40.5歲。掌側脫位損傷組患者(15例)進行掌側入路鋼板固定;背側脫位損傷組患者(19例)進行背側入路鋼板固定。腕關節(jié)功能結果:與健側肢體對比,掌側鋼板組尺偏、橈偏及旋前、旋后功能表現(xiàn)相對良好,背側鋼板組旋前功能表現(xiàn)相對良好。在握力、掌曲及背伸功能方面兩組表現(xiàn)相當。影像學結果:橈骨高度掌、背側入路均表現(xiàn)良好,均無明顯差異。DASH評分掌側脫位損傷組為18.2±15.3,背側脫位損傷組為14.5±16.4,兩組患者DASH評分結果良好。兩組對比無明顯差異。術后并發(fā)癥結果:掌側固定組1例肌腱炎,2例神經(jīng)癥狀,2例腕管綜合征,背側固定組1例肌腱斷裂,2例肌腱炎,1例神經(jīng)癥狀�？傮w并發(fā)癥發(fā)生率無明顯統(tǒng)計學差異。而我們的meta分析共有15篇文章納入研究。通過隨機效應模型發(fā)現(xiàn),掌側入路與背側入路鋼板內固定術后并發(fā)癥的總體發(fā)生率無統(tǒng)計學差異。(OR=0.79,95%CI:0.37-1.67;P=0.54)。亞組分析顯示:與背側入路鋼板固定相比,使用掌側入路鋼板固定后并發(fā)神經(jīng)病變(OR=1.83,95%CI:1.10,3.06;P=0.02)及腕管綜合征(OR=3.06;95%CI:1.07,8.79;P=0.04)的概率顯著增加,且有統(tǒng)計學意義。而使用背側入路固定后并發(fā)肌腱刺激癥(OR=0.33;95%CI:0.16,0.67;P=0.002)的概率顯著增加,且有統(tǒng)計學意義。而并發(fā)肌腱斷裂(OR=0.51;95%CI:0.22,1.16;P=0.11),復雜局部疼痛綜合征(CRPS)(OR=0.56;95%CI:0.25,1.25;P=0.16)與螺絲松動(OR=0.31;95%CI:0.08,1.31;P=0.11)的概率較大,但差異無統(tǒng)計學意義。研究結論:依據(jù)此前瞻性研究結果發(fā)現(xiàn)上述假設結論成立。伸直型損傷中間柱骨折塊及腕關節(jié)移位趨勢為向背側脫位,故應該采用背側入路,主要支撐接骨板放置于橈骨背側能很好地對抗骨折塊向背側移位趨勢。屈曲型損傷中間柱骨折塊及腕關節(jié)移位趨勢為向掌側脫位,故應該采用掌側入路,主要支撐接骨板應放置于橈骨掌側能很好地對抗骨折塊向掌側移位趨勢。此種內固定方式的選擇可最大限度避免內固定失效,防止腕關節(jié)半脫位或脫位的發(fā)生,降低手術并發(fā)癥發(fā)生率,近期臨床療效滿意。我們通過meta分析研究發(fā)現(xiàn)掌、背側入路鋼板置入固定后術后并發(fā)癥的總體發(fā)生率無顯著差異。與背側入路法相比,掌側入路鋼板固定后發(fā)生神經(jīng)病變與腕管綜合征的概率較高,而肌腱刺激癥則較低,而其他并發(fā)癥無明顯統(tǒng)計學差異。因此,我們應該摒棄固有的對背側鋼板固定的偏見,也不能成為掌側鋼板固定方式的盲目追隨者�？陀^分析可見掌、背側入路鋼板固定技術各有其自身的優(yōu)缺點,我們不能僅僅依據(jù)掌、背側入路鋼板內固定術后并發(fā)癥的發(fā)生率多少來評價孰優(yōu)孰劣,甚至決定手術策略,而應該依據(jù)橈骨遠端骨折移位趨勢特點來選擇掌側鋼板固定或是背側鋼板固定。
[Abstract]:Background: distal radius fracture is a common wrist injury. The incidence of the distal radius fracture is increasing year by year. The incidence of distal radius fractures is about 26/10000, accounting for 72% of all forearm fractures, 8~17% of all upper limb fractures, and distal radius fractures in all patients with 1/6. distal radius. The fractured patients are characterized by Shuangfeng's characteristics, namely, young patients and elderly patients. Open reduction and internal fixation is a reliable surgical technique for the treatment of distal radius fractures. However, it is still controversial whether the palmar plate or the dorsal plate is more appropriate. The dorsal plate fixation is relatively small. Analysis of the causes of this phenomenon may be influenced by traditional views. The incidence of complications after the internal fixation of the palmar plate is relatively small and the incidence of complications after the internal fixation of the dorsal plate is relatively more. There are fewer postoperative complications. But in clinical work, we found that the palmar approach plate fixation is not omnipotent. The application of the palmar plate to certain specific fracture types has encountered some serious consequences such as internal fixation failure, fracture redisplacement and even wrist dislocation. In clinical practice, we found that distal radius fractures show their respective characteristics according to the injury mechanism of injury at the time. Therefore, we assume that the orientation of the initial fracture displacement can determine the surgical strategy, and the proper application of this idea can firmly fix the displaced fracture block and reduce the occurrence of internal fixation failure accordingly. Therefore, the Department of Traumatology in our hospital has conducted a prospective experimental study to prove the difference in the incidence of complications in the treatment of distal radius fractures in adults by means of Meta analysis and comparison of the relevant literature at home and abroad. The best choice of treatment for distal radius fractures provides a clinical reference. A summary of the study in our department of Traumatology from October 2012 to October 2015 included 34 cases of distal radius fractures with targeted surgical treatment. The initial palmar displacement trend of the distal radius fracture was included in the open reduction and reduction of the palmar plate. In the fixed group (15 cases), the tendency of the dorsal displacement was included in the internal fixation group of the dorsal plate (19 cases). The main indicators were the results of the wrist joint function, the imaging results, the DASH score, and the postoperative complications. For the meta analysis, we searched for the publication of the related radius at home and abroad before January 25, 2017 under the condition of no language restriction. The clinical controlled trial of the relative complications of distal bone fractures using the palmar approach plate fixation and the dorsal plate fixation. The data of the incidence of postoperative complications were statistically analyzed with Rev Man 5 software combined with related data. Results: 34 cases of distal radius fractures were included in this clinical study, male 16 Cases, 18 women, aged 19~62 years, average 40.5 years old. Palmar dislocation injury group (15 cases) were fixed by palmar approach plate, and dorsal side dislocation group (19 cases) were fixed with dorsal approach plate. Wrist joint function results: compared with the healthy side, the palmar plate group ulnar deviation, radial deviation and pronation were relatively good, dorsal plate function was relatively good, dorsal plate The functional performance of the group was relatively good. The two groups were similar in the grip strength, the palmar flexure and the back extension function. The radiological results showed that the radial height palmar and the dorsal approach were all good. There was no significant difference in the.DASH score of the palmar dislocation in the group of 18.2 + 15.3, the dorsal side dislocation group was 14.5 + 16.4. The two groups had good results. The two groups were not compared. Postoperative complications: 1 cases of tendinitis in the palmar fixation group, 2 cases of nerve symptoms, 2 cases of carpal tunnel syndrome, 1 cases of tendon rupture in the dorsal fixation group, 2 cases of tendinitis and 1 cases of neurological symptoms. There were no significant differences in the incidence of complications in the total complication. There were 15 articles in our meta analysis. There was no significant difference in the overall incidence of complications after the lateral approach and the dorsal plate fixation. (OR=0.79,95%CI:0.37-1.67; P=0.54). The subgroup analysis showed that the neuropathy (OR=1.83,95%CI: 1.10,3.06; P=0.02) and carpal tunnel syndrome (OR=3.06; 95%CI:1.07,8) were accompanied by a palmar plate fixation compared with the dorsal approach plate fixation. The probability of.79; P=0.04) was significantly increased and statistically significant. The probability of concurrent tendon irritation (OR=0.33; 95%CI:0.16,0.67; P=0.002) after the use of the dorsal approach was significantly increased, with statistical significance. The complication of tendon rupture (OR=0.51; 95%CI:0.22,1.16; P= 0.11), and complex local pain syndrome (CRPS) (OR=0.56; 95%CI:0.25,1.25; P=0.) 16) the probability of screw loosening (OR=0.31; 95%CI:0.08,1.31; P=0.11) is larger, but the difference is not statistically significant. Conclusion: according to this prospective study, it is found that the above hypothesis is established. The fracture block and wrist displacement trend of the straight type injury middle column is to the dorsal side, so the dorsal approach should be adopted, mainly supporting the placement of the plate. On the dorsal side of the radius, the trend of the fracture block to the dorsal side of the fracture is very good. The displacement trend of the fracture block and the wrist joint is to the palmar dislocation. Therefore, the palmar approach should be adopted and the main support plate should be placed well against the palmar side of the radius. The choice of the internal fixation method is the most. In order to avoid internal fixation failure, prevent the occurrence of subluxation or dislocation of the wrist joint, reduce the incidence of surgical complications, and the recent clinical efficacy is satisfactory. We found that the overall incidence of complications after the fixation of the palmar plate after the fixation of the dorsal lateral approach plate has no significant difference. Compared with the dorsal approach, the palmar approach plate fixation is compared with the dorsal approach. The probability of subsequent neuropathy and carpal tunnel syndrome is higher, while the tendon irritation is low, but there is no significant difference in other complications. Therefore, we should abandon the inherent bias on the fixation of the dorsal plate, and can not be a blind followers of the fixation of the palmar plate. All of them have their own advantages and disadvantages. We can not only evaluate the incidence of complications after the internal fixation of the palmar and dorsal approach, and even determine the operation strategy. We should choose the palmar plate fixation or the dorsal plate fixation based on the trend characteristics of the distal radius fracture.

【學位授予單位】：天津醫(yī)科大學
【學位級別】：博士
【學位授予年份】：2017
【分類號】：R687.3

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