蹬椅取物摔倒不慎双手着地 双侧桡骨远端骨折怎么治?

2018-10-19 沈惠良 姜保国 老年骨质疏松骨折

57岁女性,蹬椅取物时不慎摔倒,头部及双手着地,即感双侧腕部疼痛,活动受限。急诊X线片:双侧桡骨远端骨折、右尺骨远端骨折。双侧肢体同时发生骨折,在一侧关节内骨折需接受手术治疗的同时,另一侧腕关节石膏固定——此方法为何不理想?

57岁女性,蹬椅取物时不慎摔倒,头部及双手着地,即感双侧腕部疼痛,活动受限。急诊X线片:双侧桡骨远端骨折、右尺骨远端骨折。双侧肢体同时发生骨折,在一侧关节内骨折需接受手术治疗的同时,另一侧腕关节石膏固定——此方法为何不理想?

【病例介绍】

患者,女性,57岁。患者入院前6小时在家中蹬椅取物时不慎摔倒,头部及双手着地,即感双侧腕部疼痛,活动受限。就诊于北京大学人民医院急诊,行X 线检查提示为“双侧桡骨远端骨折、右尺骨远端骨折”。头颅CT 提示右颞顶部可疑高密度影,不排除出血,蛛网膜下腔出血可能。遂入院行进一步治疗。既往10年前因子宫肌瘤行子宫切除术。查体:双侧腕部明显肿胀,压痛明显,腕关节活动障碍。感觉、血运正常。辅助检查:X线片(急诊):双侧桡骨远端骨折、右尺骨远端骨折(图3‐0‐3)。

图3‐0‐3 术前腕关节正侧位X 线片 (1)、(2)左腕关节;(3)、(4)右腕关节

诊断要点】

患者外伤史明确,结合查体及X 线检查,考虑双侧桡骨远端骨折、右尺骨远端骨折诊断明确。通过双腕关节正侧位X 线片分析考虑为左侧为AO分型的C1 型骨折,即完全关节内骨折,关节面简单骨折,干骺端简单骨折;右侧为AO 分型的B2 型骨折,即部分关节内骨折,桡骨背侧缘骨折。该患者为老年人,X 线片提示桡骨远端骨小梁结构变细、减少、间隙增宽,骨皮质变薄,考虑该患者同时合并有骨质疏松症。

【治疗原则】

患者骨折类型为左侧是AO 分型的C1 型骨折,右侧是AO 分型的B2 型骨折。患者同时合并有骨质疏松,分析采取的治疗方案为切开复位内固定术。

患者入院完善相关术前检查,无明显手术禁忌,遂于入院后2天在臂丛麻醉下行双侧桡骨远端骨折切开复位内固定术。

麻醉成功后患者取仰卧位,患肢外展于手术桌,手术在气囊止血带控制下进行。常规用碘酒、酒精消毒,铺单。打止血带后左侧行桡掌侧切口,显露并复位骨折。选用3 孔AO LCP钢板及锁定动力螺丝钉固定骨折。塑形后放在桡骨掌侧,T 形头向远端。在骨折线远近端各钻入3枚带锁螺丝钉。右侧行桡掌侧切口,见骨折粉碎,桡骨塌陷明显,予以复位,干骺端大量骨缺损,以人工骨移植填充骨缺损,用3 孔LCP板固定。检查发现腕关节及骨折断端稳定性良好。术中拍X 线片见骨折复位固定满意,螺钉长短合适。冲洗伤口后逐层关闭伤口。留置引流片,酒精消毒,覆盖无菌敷料,加压包扎后松止血带,石膏托制动。术后患者安全返回病房。

术后24小时拔除伤口引流条。术后第1天开始指间关节和掌指关节主动活动,同时配合肢体静脉泵消肿治疗。术后第2天减少伤口敷料,包扎后开始腕关节功能练习,由患者健侧手辅助被动活动逐渐过渡到患侧腕关节的主动活动。到伤口拆线时患侧腕关节应达到正常的活动范围。术后复查X 线片(图3‐0‐4)。

图3‐0‐4 术后腕关节正侧位X 线片 (1)、(2)左腕关节;(3)、(4)右腕关节

【随访结果】

患者术后随访结果:①左侧腕关节疼痛评价:骨折部位疼痛0分,活动时疼痛4分,腕尺侧疼痛0分。对治疗满意度6分(总分为10分,分数越小,表示疼痛越轻;分数越大,表示满意度越高)。②腕关节功能评价:患侧腕关节掌屈56°,背屈50°,桡偏22°,尺偏31°,旋前70°,旋后60°;健侧腕关节掌屈56°,背屈72°,桡偏20°,尺偏37°,旋前80°,旋后50°。③影像学评价:术后关节炎评价为无关节炎,关节面不平整度分级为0 级(0~1mm),尺偏角评价为30分(总分30分),掌倾角评价为30分(总分30分),桡骨高度评价为40分(总分40分),下尺桡关节正常,影像学评分100分。X 线片检查提示骨折愈合良好。

【经验教训】

本例患者,如单纯考虑单侧桡骨远端骨折,并无手术指征,手法复位后石膏固定即可达到良好的治疗效果。但综合患者病情,双侧肢体同时发生骨折,在一侧关节内骨折需接受手术治疗的同时,另一侧腕关节石膏固定,对于手术后的护理以及患者对生活自理能力的恢复均不利。故而选择了双侧手术治疗。以利早期活动,功能锻炼且能够生活自理。手术方法双侧均采用3.5mm LCP 进行固定。术后右侧功能恢复良好,左侧出现拇指活动受限,外展及屈曲活动疼痛。术后两个月出现右手拇指活动受限,外展肌力丧失。诊断为右侧拇长伸肌腱断裂。于我院复诊后再次住院,手术取出内固定。并在背侧切口探查修复拇长伸肌腱。手术中见掌侧螺钉穿过背侧骨皮质。考虑螺钉过长,摩擦拇长伸肌腱导致了手术后的疼痛、活动受限症状,并发展为肌腱断裂。修复肌腱后予以石膏固定。一月后拆除石膏。之后复查两年,患者双侧腕关节功能良好,右手拇指活动正常。

【专家点评】

在经典教科书中,拇长伸肌腱断裂是常见的桡骨远端骨折的并发症。原因有二:①在保守治疗的病例中,因背侧粉碎的骨块没有很好地复位,骨折片刺激拇长伸肌腱,或在骨折愈合的过程中,骨痂包绕伸肌腱腱鞘,导致伸肌腱活动受限。②采用背侧接骨板固定时,由于李斯特(Lister)结节的突起,接骨板与骨面的贴合并不理想,伸肌腱在接骨板表面的滑动造成摩擦,损伤拇长伸肌腱。故而早年也有学者提出在背侧入路时切除李斯特(Lister)结节以避免该并发症。近年来,随着掌侧接骨板的广泛应用,该并发症大大减少,同时也造成了临床上对于掌侧接骨板固定后出现的伸肌腱激惹重视不足,认为是骨折暴力引起的损伤所致。本例掌侧固定螺钉过长的原因并非仅仅是测深不准确。接骨板的偏心放置(T 形接骨板的尾端不与桡骨长轴平行)也是一个原因。由于锁定接骨板的螺钉头部与接骨板锁定,方向已然确定。在偏心放置接骨板的同时,干骺端螺钉的方向也出现了偏差。我们在回顾总结该病例的时候分析了AO 组织关于3.5mm LCP 的官方说明(Synthesis),并在骨骼标本上进行了模拟实验。干骺端的螺钉的设计方向并不能完全避开拇长伸肌腱走行区域。在接骨板尾端与桡骨骨面不平行的时候,螺钉置入点更加偏向尺侧。对于本例患者而言,锁定后螺钉更可能是从骨折线中穿出。

关节周围骨折固定的一大并发症是螺钉过长或穿入关节面造成相应的症状。桡骨远端骨折、肱骨近端骨折、股骨颈骨折、踝关节骨折固定外踝等均有可能发生此类问题。由于关节解剖复杂,手术中透视因体位、铺巾、无菌区域等原因难以获得满意的投照位置,故而对螺钉长短的判断有时较为困难。对于桡骨远端骨折而言,为避免关节面周围的螺钉穿入桡腕关节,可在螺钉打入后对腕关节进行掌屈、背伸等活动,体会有无摩擦感进行判断。判断干骺端螺钉的长短较为简单,一般腕关节纯侧位可以很好地显示螺钉与背侧骨皮质的关系。但有时因前臂位置的摆放造成斜位透视,也有可能造成手术中判断失误,应当引起重视。这是一个典型的病例,应当吸取教训。

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    2018-10-19 医者仁心5538

    学习了

    0

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