手术第1掌骨基底(关节外)骨折切开复位内固定术

1、概述           Extraarticularfracturesofthebaseofthethumbmetacarpalareoftendisplaced,withaflexiondeformityandmayshowpalmarcomminution(Wintersteinfracture).      第1掌骨基底关节外骨折通常移位明显，呈屈曲畸形，可伴有掌侧粉碎。2、移位机制  DisplacementduetomuscleforcesThepullofthethenarmusclesresultsinpalmarflexionofthedistalfragment. 骨折远端由于鱼际肌牵拉向掌侧屈曲，背侧成角3、屈曲畸形  Flexiondeformity     Iftheflexiondeformityexceeds30degrees,thumbfunctionmaybeimpairedduetomuscleimbalance.Internalfixationallowsforanatomicalreduction.     如果屈曲畸形超过30°，由于肌肉不平衡，将会影响拇指的功能，建议手术治疗，解剖复位。 4、掌侧粉碎导致不稳定  Instabilityduetopalmarcomminution     Ifstandardplatesareused,bonegraftfromthedistalradiusmaybenecessarytoavoiddelayinbonehealingandconsequentsecondarydisplacement,orfailureoffixation.Angularlystableplatefixation,usingalockingcompressionplate(LCP),preventssecondarydisplacementwithouttheneedofbonegrafting.       如果使用标准接骨板，建议从桡骨远端取骨进行移植修复以避免骨延迟愈合、骨折二次移位、内固定断裂。而角钢板、LCP钢板则可以不用行骨移植。5、使用钢板间接复位  IndirectreductionwiththeplateAngularlystableplatefixationintheproximalfragmentallowsforreductionusingtheplateasalever(asdescribedbelow).     使用锁定板可以作为一个杠杆来复位骨折端。6、牵引复位  ReductionbytractionAlternatively,andespeciallywhenaconventionalplateisused,reductioncanbeperformedwithaxialtractiononthethumb,eithermanually,orwithhelpofafingertrap,andsimultaneouspressureonthedorsalaspectofthediaphysis.      当使用普通钢板是，可通过纵向牵引来复位骨折端，同时在掌骨干背外侧给予压力。7、临时固定  PreliminarystabilizationPreliminarystabilizationcanbeachievedwithanobliquelyinsertedK-wire.Ifanatomicalreductionisdemonstratedusingimageintensification,a2mmLCPT-plateisfixedtothedorsalaspectofthefirstmetacarpalusingstandardlockingtechniques.     可以用克氏针完成临时固定，如果经透视复位满意，可以在掌骨背侧放置2mmLCP接骨板使用标准锁定技术。8、钢板长度  PlatelengthCutthe2.0mmLCPtolengthsothat2screwscanbefixedinthedistaldiaphysealfragment.        骨折远端至少有2个可以用的孔9、钢板塑形  ContouringoftheplateTheplatehastobeadaptedaccuratelytothecontouroftheproximalfragment.Usebendingplierstocontourtheplate.Becarefultobendinbetweentheholesbypositioningthepliersovertheplateholes.Alternatively,insertthethreadedboltintotheplateholestobendtheplate.Thebendshouldnevergothroughaholeasthismaydamagethelockingmechanism.钢板外形应用第1掌骨基底一致，使用折弯器来对钢板塑形，也可用套筒导向器对钢板折弯，不要对一个孔进行折弯，以免钢板产生应力断裂。 10、增加轻微弯曲  AddingaslightbendInordertopreventthescrewfrompenetratingthejoint,aslightbendisnecessary.Becarefulnottooverbend,asthereisacomminutedzoneattheoppositecortex,whichcannotwithstandcompression.为了避免螺钉穿透关节，需要对钢板进行轻微预弯，注意避免弯曲过度。 11、打入第1枚螺钉  Insertionoffirstscrew     Marktheplaneofthefirstcarpo-metacarpaljointwithathinK-wireorahypodermicneedle.Puttheplateonthedorsalaspectoftheproximalfragment,withathreadeddrillguideinoneoftheouterholes.Drillingmustbeparalleltothemarkerwire(orneedle)toensurethatthescrewwillnotpenetratethejoint.Confirmusingimageintensification.Drillthroughthethreadeddrillguide.Removethedrillguideandmeasuretheappropriatescrewlengthwithadepthgauge.Insertthelockingscrewwithoutcompletelytighteningit.      用克氏针或注射器针头标记第1腕掌关节，将钢板放置在第1掌骨背侧近端骨折块上，将钻头套筒平行克氏针放置以免打入关节，钻孔，测深，拧入螺钉。 12、使钢板的纵向序列于掌骨一致  PlatealignmentAligntheplatealongtheaxisoftheshaft. 13、打入第2枚螺钉，方法同上  Insertionof2ndscrewintheproximalfragmentInsertasecondscrewusingthesametechnique.Alwaysuseathreadeddrillguidewhenpreparingforlockingscrews. 14、使用钢板复位  Reductionbyusingtheplateasalever    Pressingtheplatedowntothediaphysealfragmentwithaperiostealelevatorwillautomaticallytiltthearticularfragmentintoitscorrectposition.Checkthereductionofthedorsalfractureline.Confirmusingimageintensification. 15、拧入远端螺钉  Insertionofdistalscrews     Insertascrewthroughthemostdistalplatehole.Thisscrewwouldnormallybeastandardscrew,asitengagesinthickcorticalbone.Alockingscrew,usingathreadeddrillguidewhendrilling,maybeinsertedinosteoporoticbone,orwhenotherwiseindicated.Theseconddistalscrewisinsertedusingthesametechnique.