distal radius fracture 桡骨远端骨折

FractureofDistalRadiusZhi-jieXi,MDThe

DepartmentoftraumaandHandSurgeryThe

First

Affiliated

Hospital

of

universityofGuangxiTraditionalChineseMedicineOutlineEpidemiologyAnatomyandbiomechanicsRadiographicalandarthroscopicevaluationClassificationCriteriaforacceptablereductionpredictorsofinstabilityComplicationAAOS-guidelinesDebatesEpidemiology

FrequencyDistalradialfracturesaccountfor1/6ofallfracturesseenintheEDRace

Noracialpreferences

havebeen

reportedAgePeaksatages5-14yearsandatages60-69years.Youngpatientsintra-articularElderlypatientsextra-articularGenderPostmenopausalwomen,female-to-maleratio4:1Adolescentboysandgirls,theratiois3:1Anatomyvolarradialtuberosity

lunatefacetbuttressPQ=PronatorQuadratusLine,orPQLine

WS=WatershedLine,

X=VolarRadialTuberosity

VR=VolarRadialRidge

Biomechanics80%oftheloadistakenonthedistalradiusand20%oftheloadistakenontheTFCCDIC=dorsalintercarpalligamentDRC=dorsalradiocarpalligamentRadiographicAssessmentX-rayCTMRIArthroscopicevaluationX-ray0.9mm10°-15°正面切线位〔11°〕侧面切线位〔21°〕标准侧位关节面切线位CTCTMRIArthroscopyClassificationFractureclassificationsystemsare,ineffect,tools.Thepurposeofthetoolistohelpthesurgeontochooseanappropriatemethodoftreatmentforeachandeveryfractureoccurringinaparticularanatomicalregion.Theclassificationtoolshouldnotonlysuggestamethodoftreatment,itshouldalsoprovidethesurgeonwithareasonablypreciseestimationoftheoutcomeofthattreatment."

------AlbertH.Burstein,PhD,DeputyEditorforResearch,

JournalofBoneandJointSurgery

Colles'fractureisanextraarticularlowenergyfractureprimarilysustainedintheelderly,afracturealmostuniquetocaucasianwomen.a"classic"Colles'fractureSirAbraham

Colles’Fracture(1814)Smith’sfracture

1847

RobertWilliamSmith

consideredthis"aninjuryofexceedinglyrareoccurrence,"butitsdescriptionheraldedtheageofvehiculartraumain1847:Thepatient,inendeavouringtosavehimselffrombeingrunoverbyacar,fellwithgreatviolenceuponthebackofhishand...RobertWilliamSmith

(1807-1873)woodcutfromSmith'soriginaldescriptionTheclassicBarton'sfracturedescribesthedorsalrimfracturesubluxation,ashear-typeinjury.JohnRheaBarton'saddressesthedifferencebetweenatruedislocationandthisfracture:adislocationtypicallyhasnocrepitus,andoncereducedtendstoremainthatwayJohnRheaBarton

(1794-1871)Barton’sFracture(1838)Diepunch

"diepunch"fracture,orlunateloadimpactfractureoftheposteromedialcorneroftheradius,wasmorerecentlydescribedby

ScheckTheabsenceofligamentousattachmentstothedepressedfragmentprecludesreduction.Inhighenergytrauma,onecomponentofanunstabledisplacedfracturetheaxialloadthroughthelunatecreates

animpact

fractureonthelunatefacetAcasereporta1a2Chauffeur'sfracture

Thebackfire,orChauffeur'sfracture,was"extremelycommoninthesedaysofvoluminoustraffic"accordingto

HaroldC.Edwards,whodescribed42fracturessustainedfromtheimpactofthedownwardswingoftheautomotivecrankhandle.Thisisahighenergystyloidfracturewithcarpal

subluxation.Salter-HarrisClassification(1963)

PediatricFractureClassification

The

growthplate

istheweakeststructureinthedevelopingendsoflongbones,andthereforeacommonsiteforinjuries,includingthedistalradius.Frykman1967Fernandez1996

TypeI:bendingTypeII:ShearingTypeIII:CompressionTypeIV:avulsion,includingradiocarpalinjuriesTypeV:combined,highenergyfracturestypeAextraarticulartypeB

partialarticularAO(1987)

typeC

completeintra-articularMedoffAnatomyClassification(1999)

Fivepredictorsofinstabilityapatientover60anintra-articularfracturedorsalincomminutiondorsalangulationofmorethan20°anassociatedulnarfractureTreatmentoptionsClosedreductionandimmobilizationClosedreductionandPercutaneouspinningExternalfixationArthroscopicallyassistedreductionandEx.Fixationofintraarticularfracture.ORIFwithplatefixationBonegraftingThereisnoconsensusonthemanagementofthesesfracturesButdefinitionsseemunclearinmanypapers.ThismightbethereasonofdiscrepancyTreatmentofTypeC3DistalRadiusFractureGuidelinesforReductionofDistalRadialFracturesRadialshortening<5mmatdistalradioulnarjointRadialinclinationonposteroanteriorradiographs>15degrees

Sagittaltiltonlateralprojectionbetween15degreesdorsaltiltand20degreesvolartiltIntraarticularstep-offorgap<2mmofradiocarpaljointArticularincongruity<2mmofsigmoidnotchofdistalradius

FunctionalEvaluationAnalysisofComplications(1)TendonIrritationorRuptureDuetoPast-pointingofDistalScrews

Allscrewsarepastthedorsalcortexandintothetendons,

butnonewillbeseenastoolongonalateralx-ray.ACaseReport

IrritationorRuptureofVolarTendonsduetoProminentPlatesorBackingOutofDistalScrewstoodistal-------intothejointtooproximal--------notsupportthesub-chondralbonetooradial---------platetiltsonthevolarradialtuberosityandmaybecomepalpableUlnocarpalImpactionSyndromeNerveInjuryIsAlsoAPossibility

PainwaspersistentanddisablingThepatientisa79yearsoldwhohada

distalradiusfracturewhichwastreatedwithanvolarplateIntraoperativeviewwiththescrewtipimpingingontheposteriorinterosseousnerveAnotherintraoperativeviewwithabetterviewofthescrewtip.ScrewsintoRadiocarpalJointPAfacetviewTiltto11°Facetlateralviewtiltto21°TruelateralviewNon-unionComplexRegionalPainSyndromeTheincidenceofCRPSafterdistalradiusfracturerangesfrom2%to39%stiffness,difficultysleeping,burningpain,andcoldsensitivityarethecommonsymptomsVitaminCatadoseof500mg/dhasbeenshowntodecreasetheincidenceConsensus-3

X-raysinnonoperativefracturesfor3weeksandstartofROM.Re-evaluatepatientswithunremittingpainduringfollow-up.PatientsperformactivefingerROM.“Intheabsenceofreliableevidenceitistheopinionoftheworkgroupthat...〞Moderate-5

ORIFforpost-reductionradialshortening>3mm,dorsaltilt>10degrees,orintra-articulardisplacementorstep-off>2mm

Rigidimmobilization>removablesplintsfordisplacedfracturestreatednon-operatively

PatientsdonotneedtobeginearlywristmotionVitaminCforthepreventionofdisproportion-atepain.14InconclusiveResultsToperformnervedecompressionwhennervedysfunctionpersistsafterreductionCastingasdefinitivetreatmentforunstablefracturesthatareinitiallyadequatelyreducedAnyonespecificoperativemethodforfixationofdistalradiusfracturesOperativetreatmentforpatientsoverage55withdistalradiusfracturesLockingplatesinpatientsovertheageof55whoaretreatedoperativelyImmobilizationoftheelbowinpatientstreatedwithcastimmobilizationUsingofbonegraft(autograftorallograft)orbonegraftsubstitutesforthefillingofabonevoidasanadjuncttootheroperativetreatmentsusingofsupplementalbonegraftsorsubstituteswhenusinglockingplatesOver-distractionofthewristwhenusinganexternalfixatorFixationof