月骨周围脱位中修复腕关节韧带的临床疗效及生物力学研究

发布时间：2018-05-10 09:32

本文选题：腕关节 + 月骨周围韧带　；参考：《河北医科大学》2015年硕士论文

【摘要】：目的:腕关节是一个结构十分复杂的复合关节,解剖结构包括8块腕骨,桡、尺骨的远端,三角纤维软骨复合体,关节囊及诸多韧带成分,这些结构组成了腕中关节、桡腕关节、桡尺远侧关节及腕骨间关节,相互联系、相互支持,共同维护腕关节的稳定和运动功能[1]。手是人的劳动器官,而腕关节则是手的支架和枢纽,因此腕关节常因外力作用而损伤,如骨折、关节脱位和韧带损伤等,造成腕关节运动的功能障碍。在腕关节的诸多损伤当中,月骨周围脱位是腕关节较为严重的一种损伤,是指桡月、尺月关节正常,月骨周围腕骨背侧或掌侧脱位。但这种疾病在临床上较为少见,约占腕部损伤的10%左右[2],且缺乏特异性的症状和体征,很容易被漏诊或误诊,回顾近年来的文献,这种疾病的早期误诊率极高,为66%~81.8%[3]。在临床中,常常有病人由于早期得不到的诊治,晚期继而出现腕关节不稳定、创伤性关节炎等,甚至出现腕骨坏死,只能进行近排腕骨切除术的治疗[4-5]。通过手术治疗月骨周围脱位来恢复腕关节的稳定性已经得到大多数手外科医师的认可,基本为切开复位内固定的手术方法。但是手术过程中是否需要修复受损腕关节韧带,这方面的研究较少,临床医生了解不明显。本研究旨在探讨在手术治疗月骨周围脱位中修复损伤韧带的临床疗效及生物力学分析,观察月骨周围脱位的韧带损伤,评估月骨周围韧带对腕关节稳定性的影响,为临床手术治疗月骨周围脱位中修复韧带的必要性提供生物力学依据。为临床上准确的诊断、指导患者治疗及腕关节功能恢复提供参考和依据。方法:2008年至2014年我科共收治了多名月骨周围脱位的患者,除去一部分行腕骨摘除手术的患者外,还有7名患者采取了切开复位内固定手术的治疗,其中单纯切开复位内固定术是4例,切开复位内固定加韧带修复的是3例。在对这7名患者随访中,参考Mayo腕关节评分法评估患者的治疗效果,通过对患者末次随访中的疼痛程度、功能状态、活动程度、握力等四方面进行评定打分,四项评分之和即为腕关节功能评分[5-6]。术后疗效根据功能评分分为四个等级,90~100为优,80~90为良,60~80为可,小于60为差,对Mayo评分结果分级后通过spss统计学软件采用秩转换的非参数检验,根据腕关节功能的评价,并随访两种手术操作的结果。然后进行生物力学实验。选用新鲜的9例自愿捐献的上肢标本,用自己制作的实验固定架固定上肢标本,通过CSS-44020系列生物力学机,使腕关节处在30°背伸、30°尺偏位置,对腕关节施加垂直负荷,速度为5N/s,当负荷达到300N后停止加速施压,维持负荷60秒,制作月骨周围背侧脱位的病理模型(损伤标本)。分离和解剖出韧带的损伤情况(舟月韧带、月三角骨韧带、桡腕背侧韧带、舟三角背侧韧带及腕骨间背侧韧带)。将上述的标本脱位的腕骨及移位的骨折块复位,再经舟状骨远侧骨折段穿针经近侧段至月骨,经三角骨穿针至月骨做固定,另一枚克氏针固定三角骨及舟状骨,拍摄平片,确定复位、穿针固定无误(即是单纯克氏针修复组)。采用4号丝线间断缝合修复上述标本中损伤的韧带(即为克氏针加韧带修复组)。并按此顺序分别对三组标本进行生物力学测试,操作CSS-44020生物力学机系统,在月骨窝和舟骨窝放置压敏片,使用自己制作的实验仪器固定上肢标本,使腕关节在背伸30°、尺偏30°位置,对腕关节施加垂直负荷,速度为5N/s,当负荷达到200N后停止加速施压,维持负荷60秒,对每组标本的压敏片测量舟骨窝和月骨窝上的压力载荷和应力区。压力敏感膜的数据得到的结果用SPSS软件进行统计学分析。结果:随访7例病人获得结果,术后随访10~26个月(平均18个月),所有患者均为一期愈合,无感染发生,对Mayo评分结果分级后通过spss统计学软件采用秩转换的非参数检验,切开复位内固定加韧带修复术优于仅仅切开复位内固定术。生物力学实验结果:通过模拟月骨周围脱位解剖和分离出损伤韧带,受损韧带以舟月韧带,月三角骨韧带为主。生物力学实验结果,月骨窝、舟骨窝所受平均压强大小均为克氏针加韧带修复组、克氏针修复组、损伤标本组依次增大。三组标本间两两比较,差异均有统计学意义(P0.05)。结论:腕关节月骨周围存在复杂的韧带结构,这些韧带对腕关节的稳定性和月骨的稳定起着重要作用。损伤可引起腕关节不稳定,在月骨周围脱位较常见。在治疗月骨周围脱位时,手术能够缓解大多数的症状,并改善腕关节的活动能力。月骨周围脱位的治疗中,单纯克氏针固定不能回复腕关节的即刻稳定性,修复月骨周围韧带可以有效减少腕关节内受力,对腕关节的稳定性起到一个重要保护作用。内固定加修复韧带术要优于单纯的内固定术。
[Abstract]:Objective: the wrist is a complex joint with a very complex structure. The anatomical structure includes 8 carpal bones, radial, ulna distal, triangular fibrocartilage complex, joint capsule and many ligaments, which constitute the wrist joint, radial wrist joint, radioulnar distal joint and carpal intercarpal joint, interrelated, support each other, and maintain wrist joint. The [1]. hand is the working organ of the human being, and the wrist joint is the support and hub of the hand, so the wrist is often damaged by external force, such as fracture, joint dislocation and ligament injury, etc., causing the dysfunction of the wrist joint movement. In the many injuries of the wrist, the dislocation of the bone around the bone is a more serious wrist joint. Injury, refers to the radial month, the ulnar joint normal, the dorsal or palmar dislocation of the carpal bone around the bone, but this disease is rare in clinical, about 10% [2] of the wrist injury, and lacks specific symptoms and signs. It is easy to be missed or misdiagnosed. The early misdiagnosis rate of this disease is very high, which is 66%~81.8%[3]. in the disease. In clinic, there are often patients with early diagnosis, instability of wrist joint, traumatic arthritis, and even carpal bone necrosis in the late stage, only the treatment of near row carpal bone excision can only be done by [4-5]. to restore the stability of the wrist through surgical treatment of the dislocation of the bone around the bone, which has been recognized by most hand surgeons. It is essential for open reduction and internal fixation. But whether the injured wrist ligament needs to be repaired or not, there are few studies in this area, and the clinicians do not understand it. The purpose of this study is to explore the clinical and biomechanical analysis of the repair of damaged ligaments in the surgical treatment of peripheral dislocation of the bone, and to observe the dislocation of the bone around the bone. The effects of ligaments of the ligaments on the stability of the wrist joint were evaluated to provide a biomechanical basis for the necessity of repairing the ligaments in the peripheral dislocation of the bone in clinical operation. It provides a reference and basis for the clinical diagnosis, the treatment of the patients and the recovery of the wrist function. Methods: from 2008 to 2014, our department treated a total of more. 7 patients were treated with open reduction and internal fixation, including 4 cases of open reduction and internal fixation, 3 cases with open reduction and internal fixation plus ligamentous repair. In the follow-up of these 7 patients, the Mayo wrist joint score was used to evaluate the patients. The curative effect of the patients was evaluated by four aspects of the pain degree, function state, activity degree and grip strength in the last follow-up of patients. The four scores were divided into four grades according to the function score of the wrist joint function score [5-6]., 90~100 was good, 80~90 was good, 60~80 was good, less than 60 was poor, and the result of Mayo score was the result. After the classification, the SPSS statistical software was used for the non parametric test of the rank conversion, according to the evaluation of the wrist joint function and the follow-up of the results of the two operations. Then, the biomechanical experiment was carried out. The fresh 9 cases of voluntary donation were selected to fix the upper limb specimens with their own experimental fixators and through the CSS-44020 series of biomechanics. The wrist joint was located at 30 degrees and 30 degrees. The vertical load was applied to the wrist joint. The speed of the wrist joint was 5N/s. When the load reached 300N, the pressure was stopped and the load was maintained for 60 seconds. The pathological model of the dorsal dislocation of the bone around the bone was made (the damaged specimen). Ligaments, the dorsal ligaments of the canoe triangle and the dorsal ligaments of the carpal bone. The carpal bone and displaced fracture blocks of the above specimens were reset, and then the distal scaphoid fractures were transacted through the proximal segment to the moon bone, the triangulation needle was fixed to the moon bone, the other Kirschner fixed the triangulate and scaphoid, and the plate was fixed, the reduction was fixed, and the puncture needle was fixed and fixed. Error (that is, simple Kirschner stitch repair group). Repair the injured ligaments (Kirschner's needles and ligaments) with 4 silk thread suture, and carry out biomechanical tests on three groups of specimens in this order, operate the CSS-44020 biomechanics system, put pressure sensitive tablets in the moon's fossa and scaphoid fossa, and use their own production The instruments were fixed on the upper limb specimens, and the wrist joint was extended 30 degrees in the back and the foot was 30 degrees. The vertical load was applied to the wrist joint, the speed was 5N/s. When the load reached 200N, the pressure was stopped and the load was maintained for 60 seconds. The pressure sensitive film of the scaphoid fossa and the bone pit was measured and the data obtained by pressure sensitive film were obtained. SPSS software was used for statistical analysis. Results: 7 patients were followed up and followed up for 10~26 months (average 18 months). All the patients were one period of healing and no infection occurred. The Mayo score was classified by the SPSS statistical software and the non parametric test was used by the rank conversion. The open reduction and internal fixation plus ligament repair was superior to the only cut. Open reduction internal fixation. Biomechanical results: the damaged ligaments were dissected and separated by the simulation of the dislocation of the bone around the bone. The damaged ligaments were based on the ligaments of the moon's moon and the lunate ligament. The results of the biomechanics experiment, the average pressure of the bone fossa and the scaphoid fossa were all the Kirschner and the ligament repair group, the Kirschner's repair group and the injury specimen group. The difference was statistically significant between the three groups of specimens (P0.05). Conclusion: there is a complex ligament structure around the wrist in the wrist joint. These ligaments play an important role in the stability of the wrist and the stability of the bone. The injury may cause the instability of the wrist joint, and the dislocation around the bone is common. The dislocation around the bone is treated around the moon. The operation can relieve most of the symptoms and improve the ability of the wrist joint. In the treatment of the dislocation of the bone around the bone, the simple Kirschner pin can not restore the immediate stability of the wrist. The repair of the ligaments around the bone can effectively reduce the internal force of the wrist and play an important protective effect on the stability of the wrist. Internal fixation is used to repair the wrist. The complex ligament operation is superior to the simple internal fixation.

【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R687.4

【参考文献】