distal-radius-fracture-桡骨远端骨折

FractureofDistalRadiusZhi-jieXi,MDTheDepartmentoftraumaandHandSurgeryTheFirstAffiliatedHospitalofuniversityofGuangxiTraditionalChineseMedicineOutline•Epidemiology•Anatomyandbiomechanics•Radiographicalandarthroscopicevaluation•Classification•Criteriaforacceptablereduction•predictorsofinstability•Complication•AAOS-guidelines•DebatesEpidemiologyFrequencyDistalradialfracturesaccountfor1/6ofallfracturesseenintheEDRaceNoracialpreferenceshavebeenreportedAge–Peaksatages5-14yearsandatages60-69years.–Youngpatientsintra-articular–Elderlypatientsextra-articularGender–Postmenopausalwomen,female-to-maleratio4:1Adolescentboysandgirls,theratiois3:1AnatomyvolarradialtuberositylunatefacetbuttressPQ=PronatorQuadratusLine,orPQLineWS=WatershedLine,X=VolarRadialTuberosityVR=VolarRadialRidgeBiomechanics80%oftheloadistakenonthedistalradiusand20%oftheloadistakenontheTFCCDIC=dorsalintercarpalligamentDRC=dorsalradiocarpalligamentRadiographicAssessment•X-ray•CT•MRI•ArthroscopicevaluationX-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CTCTMRIArthroscopyClassification•Fractureclassificationsystemsare,ineffect,tools.Thepurposeofthetoolistohelpthesurgeontochooseanappropriatemethodoftreatmentforeachandeveryfractureoccurringinaparticularanatomicalregion.Theclassificationtoolshouldnotonlysuggestamethodoftreatment,itshouldalsoprovidethesurgeonwithareasonablypreciseestimationoftheoutcomeofthattreatment.------AlbertH.Burstein,PhD,DeputyEditorforResearch,JournalofBoneandJointSurgery•Colles'fractureisanextraarticularlowenergyfractureprimarilysustainedintheelderly,afracturealmostuniquetocaucasianwomen.aclassicColles'fractureSirAbrahamColles’Fracture(1814)Smith’sfracture1847•RobertWilliamSmithconsideredthisaninjuryofexceedinglyrareoccurrence,butitsdescriptionheraldedtheageofvehiculartraumain1847:•Thepatient,inendeavouringtosavehimselffrombeingrunoverbyacar,fellwithgreatviolenceuponthebackofhishand...RobertWilliamSmith(1807-1873)woodcutfromSmith'soriginaldescription•TheclassicBarton'sfracturedescribesthedorsalrimfracturesubluxation,ashear-typeinjury.JohnRheaBarton'saddressesthedifferencebetweenatruedislocationandthisfracture:adislocationtypicallyhasnocrepitus,andoncereducedtendstoremainthatwayJohnRheaBarton(1794-1871)Barton’sFracture(1838)Diepunch•diepunchfracture,orlunateloadimpactfractureoftheposteromedialcorneroftheradius,wasmorerecentlydescribedbyScheckTheabsenceofligamentousattachmentstothedepressedfragmentprecludesreduction.Inhighenergytrauma,onecomponentofanunstabledisplacedfracturetheaxialloadthroughthelunatecreatesanimpactfractureonthelunatefacetAcasereporta1a2Chauffeur'sfracture•Thebackfire,orChauffeur'sfracture,wasextremelycommoninthesedaysofvoluminoustrafficaccordingtoHaroldC.Edwards,whodescribed42fracturessustainedfromtheimpactofthedownwardswingoftheautomotivecrankhandle.Thisisahighenergystyloidfracturewithcarpalsubluxation.Salter-HarrisClassification(1963)•PediatricFractureClassification•Thegrowthplateistheweakeststructureinthedevelopingendsoflongbones,andthereforeacommonsiteforinjuries,includingthedistalradius.Frykman1967Fernandez1996TypeI:bendingTypeII:ShearingTypeIII:CompressionTypeIV:avulsion,includingradiocarpalinjuriesTypeV:combined,highenergyfracturestypeAextraarticulartypeBpartialarticularAO(1987)typeCcompleteintra-articularMedoffAnatomyClassification(1999)Fivepredictorsofinstability•apatientover60•anintra-articularfracture•dorsalincomminution•dorsalangulationofmorethan20°•anassociatedulnarfractureTreatmentoptions•Closedreductionandimmobilization•ClosedreductionandPercutaneouspinning•Externalfixation•ArthroscopicallyassistedreductionandEx.Fixationofintraarticularfracture.•ORIFwithplatefixation•BonegraftingThereisnoconsensusonthemanagementofthesesfracturesButdefinitionsseemunclearinmanypapers.ThismightbethereasonofdiscrepancyTreatmentofTypeC3DistalRadiusFractureGuidelinesforReductionofDistalRadialFractures•Radialshortening5mmatdistalradioulnarjoint•Radialinclinationonposteroanteriorradiographs15degrees•Sagittaltiltonlateralprojectionbetween15degreesdorsaltiltand20degreesvolartilt•Intraarticularstep-offorgap2mmofradiocarpaljoint•Articularincongruity2mmofsigmoidnotchofdistalradiusFunctionalEvaluationAnalysisofComplications•(1)TendonIrritationorRuptureDuetoPast-pointingofDistalScrewsAllscrewsarepastthedorsalcortexandintothetendons,butnonewillbeseenastoolongonalateralx-ray.ACaseReportIrritationorRuptureofVolarTendonsduetoProminentPlatesorBackingOutofDistalScrews•toodistal-------intothejoint•tooproximal--------notsupportthesub-chondralbone•tooradial---------platetiltsonthevolarradialtuberosityandmaybecomepalpableUlnocarpalImpactionSyndromeNerveInjuryIsAlsoAPossibilityPainwaspersistentanddisablingThepatientisa79yearsoldwhohadadistalradiusfracturewhichwastreatedwithanvolarplateIntraoperativeviewwiththescrewtipimpingingontheposteriorinterosseousnerveAnotherintraoperativeviewwithabetterviewofthescrewtip.ScrewsintoRadiocarpalJointPAfacetviewTiltto11°Facetlateralviewtiltto21°TruelateralviewNon-unionComplexRegionalPainSyndrome•Theincid