桡骨远端骨折治疗的临床研究和荟萃分析

发布时间：2018-05-05 10:43

本文选题：骨折 + 桡骨远端　；参考：《天津医科大学》2017年博士论文

【摘要】：研究背景:桡骨远端骨折是常见的腕部损伤,其发生率呈现出逐年增长的趋势。桡骨远端骨折病人的发生率每年大约为26/10000,占到所有前臂骨折患者的72%,占所有上肢骨折患者的8~17%,桡骨远端骨折病人占所有急诊患者的1/6。桡骨远端骨折患者呈现出双峰特征,即青年患者和老年患者。目前,切开复位钢板内固定手术是治疗桡骨远端骨折一项可靠的手术技术。但究竟是掌侧钢板固定还是背侧钢板固定更恰当,仍存在争论。在临床上,桡骨远端骨折掌侧钢板固定非常流行,背侧入路钢板固定则相对较少。分析发生此现象的原因,可能受到传统观点影响,认为掌侧钢板内固定术后并发症发生率相对较少,背侧钢板内固定术后并发症发生率相对较多。随着最新研制的超薄低切迹背侧钢板的出现,背侧钢板固定出现了更少的术后并发症。但在临床工作中我们发现,掌侧入路钢板固定并不是万能的,掌侧钢板固定在某些特定骨折类型上的应用遭遇了一些内固定失败,骨折再移位甚至腕关节脱位等严重后果。这引起了我们的反思。研究目的:在临床实践中我们发现,桡骨远端骨折根据受伤当时的损伤机制,骨折形态表现出其各自特点。因此我们假设初始骨折移位方向能够决定手术治疗策略,并且恰当应用此理念能够牢固固定移位骨折块并能相应减少术后内固定失败的发生率。因此我院创伤科进行了一项前瞻性的实验研究来进行佐证。并且针对大家对背侧钢板内固定的偏见,我们通过查阅国内外相关文献,利用Meta分析比较掌、背侧钢板内固定治疗成人桡骨远端骨折术后并发症发生率的差异,为探究治疗桡骨远端骨折的最优治疗选择提供临床参考依据。研究方法:总结我院创伤科自2012年10月至2015年10月之间纳入此项前瞻性研究有针对性手术治疗的桡骨远端骨折病例34例。依据桡骨远端骨折初始掌侧移位趋势纳入切开复位掌侧钢板内固定组(15例),背侧移位趋势则纳入背侧钢板内固定组(19例)。治疗主要观察指标:腕关节功能结果,影像学结果,DASH评分及术后并发症等。对于meta分析研究,我们在无语种限制的条件下检索在2017年1月25日之前在国内外公开发表的有关桡骨远端骨折使用掌侧入路钢板固定和背侧入路钢板固定术后相关并发症对比的临床对照试验。使用Rev Man 5软件合并相关数据,对各种术后并发症的发生率等数据进行统计分析。研究结果:本临床研究共纳入桡骨远端骨折患者34例,男16例,女18例;年龄19~62岁,平均40.5岁。掌侧脱位损伤组患者(15例)进行掌侧入路钢板固定;背侧脱位损伤组患者(19例)进行背侧入路钢板固定。腕关节功能结果:与健侧肢体对比,掌侧钢板组尺偏、桡偏及旋前、旋后功能表现相对良好,背侧钢板组旋前功能表现相对良好。在握力、掌曲及背伸功能方面两组表现相当。影像学结果:桡骨高度掌、背侧入路均表现良好,均无明显差异。DASH评分掌侧脱位损伤组为18.2±15.3,背侧脱位损伤组为14.5±16.4,两组患者DASH评分结果良好。两组对比无明显差异。术后并发症结果:掌侧固定组1例肌腱炎,2例神经症状,2例腕管综合征,背侧固定组1例肌腱断裂,2例肌腱炎,1例神经症状。总体并发症发生率无明显统计学差异。而我们的meta分析共有15篇文章纳入研究。通过随机效应模型发现,掌侧入路与背侧入路钢板内固定术后并发症的总体发生率无统计学差异。(OR=0.79,95%CI:0.37-1.67;P=0.54)。亚组分析显示:与背侧入路钢板固定相比,使用掌侧入路钢板固定后并发神经病变(OR=1.83,95%CI:1.10,3.06;P=0.02)及腕管综合征(OR=3.06;95%CI:1.07,8.79;P=0.04)的概率显著增加,且有统计学意义。而使用背侧入路固定后并发肌腱刺激症(OR=0.33;95%CI:0.16,0.67;P=0.002)的概率显著增加,且有统计学意义。而并发肌腱断裂(OR=0.51;95%CI:0.22,1.16;P=0.11),复杂局部疼痛综合征(CRPS)(OR=0.56;95%CI:0.25,1.25;P=0.16)与螺丝松动(OR=0.31;95%CI:0.08,1.31;P=0.11)的概率较大,但差异无统计学意义。研究结论:依据此前瞻性研究结果发现上述假设结论成立。伸直型损伤中间柱骨折块及腕关节移位趋势为向背侧脱位,故应该采用背侧入路,主要支撑接骨板放置于桡骨背侧能很好地对抗骨折块向背侧移位趋势。屈曲型损伤中间柱骨折块及腕关节移位趋势为向掌侧脱位,故应该采用掌侧入路,主要支撑接骨板应放置于桡骨掌侧能很好地对抗骨折块向掌侧移位趋势。此种内固定方式的选择可最大限度避免内固定失效,防止腕关节半脱位或脱位的发生,降低手术并发症发生率,近期临床疗效满意。我们通过meta分析研究发现掌、背侧入路钢板置入固定后术后并发症的总体发生率无显著差异。与背侧入路法相比,掌侧入路钢板固定后发生神经病变与腕管综合征的概率较高,而肌腱刺激症则较低,而其他并发症无明显统计学差异。因此,我们应该摒弃固有的对背侧钢板固定的偏见,也不能成为掌侧钢板固定方式的盲目追随者。客观分析可见掌、背侧入路钢板固定技术各有其自身的优缺点,我们不能仅仅依据掌、背侧入路钢板内固定术后并发症的发生率多少来评价孰优孰劣,甚至决定手术策略,而应该依据桡骨远端骨折移位趋势特点来选择掌侧钢板固定或是背侧钢板固定。
[Abstract]:Background: distal radius fracture is a common wrist injury. The incidence of the distal radius fracture is increasing year by year. The incidence of distal radius fractures is about 26/10000, accounting for 72% of all forearm fractures, 8~17% of all upper limb fractures, and distal radius fractures in all patients with 1/6. distal radius. The fractured patients are characterized by Shuangfeng's characteristics, namely, young patients and elderly patients. Open reduction and internal fixation is a reliable surgical technique for the treatment of distal radius fractures. However, it is still controversial whether the palmar plate or the dorsal plate is more appropriate. The dorsal plate fixation is relatively small. Analysis of the causes of this phenomenon may be influenced by traditional views. The incidence of complications after the internal fixation of the palmar plate is relatively small and the incidence of complications after the internal fixation of the dorsal plate is relatively more. There are fewer postoperative complications. But in clinical work, we found that the palmar approach plate fixation is not omnipotent. The application of the palmar plate to certain specific fracture types has encountered some serious consequences such as internal fixation failure, fracture redisplacement and even wrist dislocation. In clinical practice, we found that distal radius fractures show their respective characteristics according to the injury mechanism of injury at the time. Therefore, we assume that the orientation of the initial fracture displacement can determine the surgical strategy, and the proper application of this idea can firmly fix the displaced fracture block and reduce the occurrence of internal fixation failure accordingly. Therefore, the Department of Traumatology in our hospital has conducted a prospective experimental study to prove the difference in the incidence of complications in the treatment of distal radius fractures in adults by means of Meta analysis and comparison of the relevant literature at home and abroad. The best choice of treatment for distal radius fractures provides a clinical reference. A summary of the study in our department of Traumatology from October 2012 to October 2015 included 34 cases of distal radius fractures with targeted surgical treatment. The initial palmar displacement trend of the distal radius fracture was included in the open reduction and reduction of the palmar plate. In the fixed group (15 cases), the tendency of the dorsal displacement was included in the internal fixation group of the dorsal plate (19 cases). The main indicators were the results of the wrist joint function, the imaging results, the DASH score, and the postoperative complications. For the meta analysis, we searched for the publication of the related radius at home and abroad before January 25, 2017 under the condition of no language restriction. The clinical controlled trial of the relative complications of distal bone fractures using the palmar approach plate fixation and the dorsal plate fixation. The data of the incidence of postoperative complications were statistically analyzed with Rev Man 5 software combined with related data. Results: 34 cases of distal radius fractures were included in this clinical study, male 16 Cases, 18 women, aged 19~62 years, average 40.5 years old. Palmar dislocation injury group (15 cases) were fixed by palmar approach plate, and dorsal side dislocation group (19 cases) were fixed with dorsal approach plate. Wrist joint function results: compared with the healthy side, the palmar plate group ulnar deviation, radial deviation and pronation were relatively good, dorsal plate function was relatively good, dorsal plate The functional performance of the group was relatively good. The two groups were similar in the grip strength, the palmar flexure and the back extension function. The radiological results showed that the radial height palmar and the dorsal approach were all good. There was no significant difference in the.DASH score of the palmar dislocation in the group of 18.2 + 15.3, the dorsal side dislocation group was 14.5 + 16.4. The two groups had good results. The two groups were not compared. Postoperative complications: 1 cases of tendinitis in the palmar fixation group, 2 cases of nerve symptoms, 2 cases of carpal tunnel syndrome, 1 cases of tendon rupture in the dorsal fixation group, 2 cases of tendinitis and 1 cases of neurological symptoms. There were no significant differences in the incidence of complications in the total complication. There were 15 articles in our meta analysis. There was no significant difference in the overall incidence of complications after the lateral approach and the dorsal plate fixation. (OR=0.79,95%CI:0.37-1.67; P=0.54). The subgroup analysis showed that the neuropathy (OR=1.83,95%CI: 1.10,3.06; P=0.02) and carpal tunnel syndrome (OR=3.06; 95%CI:1.07,8) were accompanied by a palmar plate fixation compared with the dorsal approach plate fixation. The probability of.79; P=0.04) was significantly increased and statistically significant. The probability of concurrent tendon irritation (OR=0.33; 95%CI:0.16,0.67; P=0.002) after the use of the dorsal approach was significantly increased, with statistical significance. The complication of tendon rupture (OR=0.51; 95%CI:0.22,1.16; P= 0.11), and complex local pain syndrome (CRPS) (OR=0.56; 95%CI:0.25,1.25; P=0.) 16) the probability of screw loosening (OR=0.31; 95%CI:0.08,1.31; P=0.11) is larger, but the difference is not statistically significant. Conclusion: according to this prospective study, it is found that the above hypothesis is established. The fracture block and wrist displacement trend of the straight type injury middle column is to the dorsal side, so the dorsal approach should be adopted, mainly supporting the placement of the plate. On the dorsal side of the radius, the trend of the fracture block to the dorsal side of the fracture is very good. The displacement trend of the fracture block and the wrist joint is to the palmar dislocation. Therefore, the palmar approach should be adopted and the main support plate should be placed well against the palmar side of the radius. The choice of the internal fixation method is the most. In order to avoid internal fixation failure, prevent the occurrence of subluxation or dislocation of the wrist joint, reduce the incidence of surgical complications, and the recent clinical efficacy is satisfactory. We found that the overall incidence of complications after the fixation of the palmar plate after the fixation of the dorsal lateral approach plate has no significant difference. Compared with the dorsal approach, the palmar approach plate fixation is compared with the dorsal approach. The probability of subsequent neuropathy and carpal tunnel syndrome is higher, while the tendon irritation is low, but there is no significant difference in other complications. Therefore, we should abandon the inherent bias on the fixation of the dorsal plate, and can not be a blind followers of the fixation of the palmar plate. All of them have their own advantages and disadvantages. We can not only evaluate the incidence of complications after the internal fixation of the palmar and dorsal approach, and even determine the operation strategy. We should choose the palmar plate fixation or the dorsal plate fixation based on the trend characteristics of the distal radius fracture.

【学位授予单位】：天津医科大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R687.3

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