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第5掌骨颈骨折在手部骨折中较为多见,国内学者统计所占比例约0.28%[1],国外报道高达20%[2]。其传统治疗方法多将掌指关节及指间关节均屈曲90°位石膏固定,容易造成关节僵硬,掌板及侧副韧带挛缩。而切开复位内固定,术中需切开腱帽、牵拉或劈开伸肌腱,容易导致肌腱粘连、关节挛缩和令人讨厌的瘢痕[3-4],且需剥离局部骨膜势必影响血运及骨折愈合。闭合克氏针内固定易穿入并损伤关节软骨、伸肌腱及其腱帽、韧带、骨间肌等结构,造成硬性阻挡,无法早期训练[5-6]。也有将克氏针穿第5掌骨后打入第4掌骨,借助临近掌骨形成内固定支架进而稳定第5掌骨颈骨折的复位[3, 7-11],此类方法进一步影响了第4掌指关节及其周围肌腱韧带结构。也有人采用顺行交叉髓内针[12],但操作复杂、开髓较大,容易导致克氏针松脱。另外,克氏针外露,针尾留于体外易刺激皮肤且容易引起针道感染[13]。因此,我们对于满足条件的病例提倡闭合复位经皮顺行单根克氏针髓内固定。KAISSAR等[14]通过系统评价及Meta分析也认同顺行髓内固定治疗第5掌骨颈骨折比钢板或其他内固定方法更有优势。本研究[15]认为,此手术方法避免了对掌指关节结构的干扰,最大限度减少对伸肌腱的损伤,术后不需长期固定,可早期训练,使手功能能够迅速恢复。基于此优势,我们对符合要求的第5掌骨颈闭合骨折病人采用此方法,通过数据测量使此手术方法达到更加精准微创的目的。
经皮克氏针改良髓内固定第5掌骨颈骨折疗效分析
Modified percutaneous intramedullary fixation with Kirschner wire for treatment of the fifth metacarpal neck fracture
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摘要:
目的探讨经皮克氏针改良髓内固定第5掌骨颈骨折的治疗效果。 方法选择24例第5掌骨颈闭合骨折病人,按治疗方法分为对照组(n=11)和手术组(n=13)。对照组采用传统手法复位石膏外固定进行治疗,手术组采用闭合复位经皮克氏针改良髓内固定方法进行治疗。采用总主动活动度(TAM)系统评定法评定2组病人的功能恢复情况。 结果闭合复位经皮克氏针改良髓内固定手术时间为15~25 min,术后复查X线片提示骨折复位良好。TAM系统评定法评定结果显示,手术组:优10例,良3例;对照组:优3例,良4例,可4例。2组治疗效果差异有统计学意义(uc=2.40,P < 0.05)。术后手术组未出现针尾滑囊炎及尺神经手背支激惹或损伤。 结论闭合复位经皮克氏针改良髓内固定治疗第5掌骨颈骨折,手术简单易行,外固定时间短,创伤小,并发症少,效果满意,值得推广。 Abstract:ObjectiveTo evaluate the effect of modified percutaneous intramedullary fixation with Kirschner wire for treatment of the fifth metacarpal neck fracture. MethodsA total of 24 patients with closed fracture of the fifth metacarpal neck were selected and divided into control group(n=11) and operation group(n=13) according to the treating method.The control group was treated with traditional reduction and plaster external fixation, and the operation group was treated with closed reduction and modified percutaneous intramedullary fixation with Kirschner wire.The total active movement(TAM) system was used to evaluate the functional recovery of the two groups. ResultsThe operation time of closed reduction and modified percutaneous intramedullary fixation with Kirschner wire was 15 to 25 minutes.The X-ray examination after operation indicated that the fracture was restored well.The results of TAM system showed that there were 10 excellent cases and 3 good cases in operation group, and 3 excellent cases, 4 good cases and 4 fair cases in control group, and the difference of the therapeutic effect between two groups was statistically significant (uc=2.40, P < 0.05).There was no irritation or injury of the dorsal branch of the ulnar nerve after operation in operation group. ConclusionsClosed reduction and improved percutaneous intramedullary fixation with Kirschner wire for the treatment of the fifth metacarpal neck fracture is simple and easy to operate, with short external fixation time, minimal trauma, fewer complications and satisfactory results, which is worth popularizing. -
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