目的:全面分析尺骨横向短缩截骨术治疗尺骨正向变异导致各种症状的临床效果。方法:回顾性分析2011年7月~2020年5月在我院采用尺骨横向短缩截骨术治疗尺骨正向变异引起各种症状25例的病例资料,通过比较其术前、术后的尺骨变异值、腕关节活动度、桡尺偏的范围、前臂旋转度、腕关节活动时疼痛程度、手握力、改良Sarmiento方法腕关节评分以及上肢功能DASH评分变化,对该术式临床效果进行评价。结果:25例均获随访,截骨部位均获得骨性愈合。比较其术前、术后的尺骨变异情况、腕关节活动度、桡尺偏的范围、前臂旋转度、手握力及上肢功能变化。术后尺骨正变异明显改善。腕关节的活动度有一定的好转,其中手握力、疼痛较术前改善明显;腕关节屈伸活动范围术前为健侧的(75.1 ± 10.1)%,术后为健侧的(89.1 ± 10.3)%;腕关节桡尺偏范围术前为健侧的(62.3 ± 7.9)%,术后为健侧的(87.8 ± 11.2)%;前臂旋转活动范围术前为健侧的(76.3 ± 8.2)%,术后为健侧的(91.8 ± 8.1)%;握力术前为健侧的(62.1 ± 10.1)%,术后为(90.2 ± 9.5)%;疼痛VAS评分术前为(4.6 ± 1)分,术后为(0.7 ± 0.5)分。最后一次随访时改良的Sarmiento腕关节评分平均为89.1分,优16例,良6例,可2例,差1例,优良率为88.0%。此外,术后上肢DASH评分(55.1 ± 9.5)分较术前(25.2 ± 8.7)分显著降低。结论:尺骨横向短缩截骨术治疗尺骨正向变异引起的各种症状,可缓解患者腕部疼痛,改善腕关节功能,提高手握力,是一种有效的治疗方法。 Objective: To comprehensively analyze the clinical efficiency of ulnar transverse shortening os-teotomy in the treatment of ulnar positive variance’s various symptoms. Methods: Retrospective analysis of medical records of 25 patients with ulnar positive variance’s various symptoms were treated in our hospital with transverse shortening osteotomy of the ulnar from July 2011 to May 2020, the preoperative and postoperative ulnar variation, wrist joint activity, radioulnar deviation range, forearm rotation degree, pain degree at wrist activity, handgrip strength, modified Sarmiento wrist score and change of upper limb function DASH score were compared to evaluate the clinical effect of the surgery. Results: 25 patients were fully followed up. All patients achieved bone healing. The changes in the preoperative and postoperative ulnar variation, wrist joint activity, radioulnar deviation range, forearm rotation degree, handgrip strength and upper limb function were compared. The positive variation of ulna was significantly improved after surgery. The mobility of the wrist was improved to some extent, especially hand grip strength and pain significantly compared with that before surgery. The range of motion to the healthy side gained limited increments from (75.1 ± 10.1)% to (89.1 ± 10.3)% for wrist flexion-extension, from (62.3 ± 7.9)% to (87.8 ± 11.2)% for radioulnar deviation, and from (76.3 ± 8.2)% to (91.8 ± 8.1)% for forearm rotation. The grip strength to the healthy side increased from (62.1 ± 10.1)% to (90.2 ± 9.5)%. The pain VAS score reduced from (4.6 ± 1.2)% to (0.7 ± 0.5). At the last follow-up, the modified Sarmiento to wrist score averaged 89.1 points, with 16 excellent, 6 good, 2 fair and 1 poor. The excellent and good rate was 88.0%. Besides, the DASH score of upper limb function after surgery was obviously decreased compared with that before surgery (55.1 ± 9.5) points vs. (25.2 ± 8.7) points. Conclusion: Ulnar transverse shortening osteotomy in the treatment of ulnar positive variance’s various symptoms can alleviate wrist pain, improve wrist joint function and enhance handgrip strength. It’s an effective treatment.
目的:全面分析尺骨横向短缩截骨术治疗尺骨正向变异导致各种症状的临床效果。方法:回顾性分析2011年7月~2020年5月在我院采用尺骨横向短缩截骨术治疗尺骨正向变异引起各种症状25例的病例资料,通过比较其术前、术后的尺骨变异值、腕关节活动度、桡尺偏的范围、前臂旋转度、腕关节活动时疼痛程度、手握力、改良Sarmiento方法腕关节评分以及上肢功能DASH评分变化,对该术式临床效果进行评价。结果:25例均获随访,截骨部位均获得骨性愈合。比较其术前、术后的尺骨变异情况、腕关节活动度、桡尺偏的范围、前臂旋转度、手握力及上肢功能变化。术后尺骨正变异明显改善。腕关节的活动度有一定的好转,其中手握力、疼痛较术前改善明显;腕关节屈伸活动范围术前为健侧的(75.1 ± 10.1)%,术后为健侧的(89.1 ± 10.3)%;腕关节桡尺偏范围术前为健侧的(62.3 ± 7.9)%,术后为健侧的(87.8 ± 11.2)%;前臂旋转活动范围术前为健侧的(76.3 ± 8.2)%,术后为健侧的(91.8 ± 8.1)%;握力术前为健侧的(62.1 ± 10.1)%,术后为(90.2 ± 9.5)%;疼痛VAS评分术前为(4.6 ± 1)分,术后为(0.7 ± 0.5)分。最后一次随访时改良的Sarmiento腕关节评分平均为89.1分,优16例,良6例,可2例,差1例,优良率为88.0%。此外,术后上肢DASH评分(55.1 ± 9.5)分较术前(25.2 ± 8.7)分显著降低。结论:尺骨横向短缩截骨术治疗尺骨正向变异引起的各种症状,可缓解患者腕部疼痛,改善腕关节功能,提高手握力,是一种有效的治疗方法。
尺骨正向变异,截骨
Jun Huang*, Rui Chen, Xiangting Jin, Dongyang Li
Department of Orthopaedics, The First Naval Hospital of Southern Theater Command, Zhanjiang Guangdong
Received: Aug. 21st, 2023; accepted: Sep. 28th, 2023; published: Oct. 7th, 2023
Objective: To comprehensively analyze the clinical efficiency of ulnar transverse shortening osteotomy in the treatment of ulnar positive variance’s various symptoms. Methods: Retrospective analysis of medical records of 25 patients with ulnar positive variance’s various symptoms were treated in our hospital with transverse shortening osteotomy of the ulnar from July 2011 to May 2020, the preoperative and postoperative ulnar variation, wrist joint activity, radioulnar deviation range, forearm rotation degree, pain degree at wrist activity, handgrip strength, modified Sarmiento wrist score and change of upper limb function DASH score were compared to evaluate the clinical effect of the surgery. Results: 25 patients were fully followed up. All patients achieved bone healing. The changes in the preoperative and postoperative ulnar variation, wrist joint activity, radioulnar deviation range, forearm rotation degree, handgrip strength and upper limb function were compared. The positive variation of ulna was significantly improved after surgery. The mobility of the wrist was improved to some extent, especially hand grip strength and pain significantly compared with that before surgery. The range of motion to the healthy side gained limited increments from (75.1 ± 10.1)% to (89.1 ± 10.3)% for wrist flexion-extension, from (62.3 ± 7.9)% to (87.8 ± 11.2)% for radioulnar deviation, and from (76.3 ± 8.2)% to (91.8 ± 8.1)% for forearm rotation. The grip strength to the healthy side increased from (62.1 ± 10.1)% to (90.2 ± 9.5)%. The pain VAS score reduced from (4.6 ± 1.2)% to (0.7 ± 0.5). At the last follow-up, the modified Sarmiento to wrist score averaged 89.1 points, with 16 excellent, 6 good, 2 fair and 1 poor. The excellent and good rate was 88.0%. Besides, the DASH score of upper limb function after surgery was obviously decreased compared with that before surgery (55.1 ± 9.5) points vs. (25.2 ± 8.7) points. Conclusion: Ulnar transverse shortening osteotomy in the treatment of ulnar positive variance’s various symptoms can alleviate wrist pain, improve wrist joint function and enhance handgrip strength. It’s an effective treatment.
Keywords:Ulnar Positive Variance, Osteotomy
Copyright © 2023 by author(s) and beplay安卓登录
This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).
http://creativecommons.org/licenses/by/4.0/
在全体健康人群中,尺骨正向变异为48.9% [
本组共25病例,男14例,女11例;年龄19~56岁,平均39岁。均为左侧或右侧单侧病变,左侧尺骨正变异7例,右侧尺骨正变异18例。术后门诊随访、回访15~22个月,平均18个月。尺骨正向变异原因:7例为尺骨先天性或发育性病变,2例为尺骨骨折后尺骨增长,16例继发于桡骨远端骨折后桡骨短缩,伴有下尺桡关节脱位或半脱位5例。所有病例均为腕尺侧疼痛、压痛,17例存在MRI或CT成像表现为月骨囊性改变。
病例纳入标准:1) 腕关节疼痛病史,前臂旋前或施加握力时加重,腕关节尺侧压痛阳性;2) 有腕关节外伤史或特殊的手部工作史;3) 挤压腕关节旋转尺偏时出现疼痛 [
术前X线测量:先沿桡骨纵轴画一直线,自尺骨头关节面和桡骨远端关节面分别向桡骨纵轴线画垂线,测量两垂线间的距离,即为尺骨变异值(见图1)。这里所说的尺骨变异是指尺骨头与桡骨远端关节面的相对长短。尺骨头长于桡骨远端关节面为正向变异(亦称阳性变异),反之为负向变异(亦称阴性变异),两者一致为零变异(亦称中性变异)。所有病例术前均属于尺骨正向变异,变异范围2.0~11 mm,平均5.7 mm。所有患者,术前均告知手术风险、意外及术后注意事项等情况,他们均表示理解并同意手术并签字,同时获经医院伦理委员会批准。
图1. 尺骨变异值测量
取仰卧位,上肢外展,臂丛神经阻滞麻醉,上臂电动气压止血带。于尺骨下段背侧纵行切开皮肤及皮下,长约7 cm,在尺侧腕伸肌与腕屈肌间隙进入,显露尺骨干,辨认并保护尺神经及其腕分支;于尺骨茎突上端约5.0 cm处,按术前测量尺骨正向变异长度横行截除一段尺骨;将尺骨断端复好位,无旋转。通常选用6孔直钢板(见病例1)或5孔“T”型钢板(见病例2)固定,钢板远端距离尺骨茎突约1 cm,截骨面远端至少3枚螺钉固定。如伴有下尺桡关节脱位或半脱位尺骨向背侧翘起,将尺骨用手指按压复位,同时自尺骨远端横向穿一枚柯氏针至桡骨远端(见图2左侧)。冲洗创面后缝合伤口,同时放置引流片1枚。
Case 1. Images before and after surgery
病例1. 手术前、后图片
图2. 下尺桡关节横向柯氏针固定前、后图片
不做外固定,常规输注抗生素1 d。尽早进行功能锻炼,早期进行掌指关节及腕关节屈伸锻炼,3周后尺桡偏锻炼腕关节,6周后旋转前臂。稳中求进行前臂旋转,重视动静结合 [
术后定期拍摄X线片,以了解尺骨愈合情况及手术前、后尺骨变异情况。拍摄尺桡骨正侧位(含腕关节) X线片,并记录截骨处有无移位、骨吸收、感染及骨不连等并发症。尺骨变异值测量同术前测量方法。术后1、2、3月门诊随访、回访,以后每3个月随访、回访1次,同时评价腕关节功能,主要包括手指、腕关节屈伸、前臂旋转、腕关节尺桡偏、疼痛程度、手握力、改良的Sarmiento评分等方面及上肢功能DASH评分。测量腕关节旋前、旋后、屈伸及尺桡偏范围,用角度计测量3次,取其平均值。使用Juwairen握力计测量手握力,取3次平均值。VAS评分法评估疼痛程度。改良的Sarmiento评分评价腕关节总体功能,标准为:优90~100,良80~90,可60~80,差<60。采用DASH评价表评估上肢功能,评分越低显示功能越好。
统计学分析采用SPSS 15.0统计学软件,百分比(%)表示定性资料,用x2检验;定量资料(前臂旋转及腕关节屈伸活动度、桡尺偏范围、手握力、改良Sarmiento腕关节评分、VAS评分、DASH评分)采用( x ¯ ± s )表示,用t检验,P < 0.05有统计学意义。
本文25例病人全获随访,随访15~24个月,平均18个月。手术伤口均愈合良好。术后X线检查显示尺骨截骨处全都骨性愈合,愈合时间5~14个月,平均11个月。没有发生截骨移位、骨不连、感染、内固定松动断裂等并发症。25例患者中,术后13例患者获得尺骨轻度负向变异,1例轻度正向变异(2 mm以内),11例零变异。术后尺骨正向变异值明显减少,甚至变为轻度负变异,且术后手握力恢复较明显(P < 0.05) (见表1)。
时间 | 尺骨变异值 | 握力 |
---|---|---|
术前(n = 25) | 5.7 ± 1.1 | 65.8 ± 10.1 |
术后(n = 25) | −0.2 ± 0.6 | 90.2 ± 9.5 |
t | 23.54 | −8.79 |
P | <0.05 | <0.05 |
表1. 尺骨变异值、手握力变化( x ¯ ± s )
术后前臂旋转度、腕关节尺桡偏范围、腕关节屈伸范围均较术前显著增加(P < 0.05) (见表2)。
时间 | 前臂旋转度 | 腕关节屈伸度 | 腕关节尺桡偏度 |
---|---|---|---|
术前(n = 25) | 76.3 ± 8.2 | 75.1 ± 10.1 | 62.3 ± 7.9 |
术后(n = 25) | 91.8 ± 8.1 | 89.1 ± 10.3 | 87.8 ± 11.2 |
t | −5.42 | −4.85 | −9.29 |
P | <0.05 | <0.05 | <0.05 |
表2. 术前、术后腕关节活动变化( x ¯ ± s )
术后腕关节疼痛明显减轻,术后VAS评分与术前比较有统计学意义(P < 0.05);改良Sarmiento腕关节评分值术后较术前明显增加(P < 0.05)。最后一次随访、回访时改良的Sarmiento评分平均为89.1分,优16例,良6例,可2例,差1例,优良率为88%。同时,术后患者上肢功能有不同程度的改善,DASH评分较术前降低(P < 0.05) (见表3)。
时间 | VAS评分 | Sarmiento评分 | DASH评分 |
---|---|---|---|
术前(n = 25) | 4.6 ± 1.2 | 60.2 ± 14.8 | 55.1 ± 9.5 |
术后(n = 25) | 0.7 ± 0.5 | 89.1 ± 10.2 | 25.2 ± 8.7 |
t | 15.0 | −8.04 | 11.61 |
P | <0.05 | <0.05 | <0.05 |
表3. VAS评分、改良Sarmiento评分及上肢DASH评分情况( x ¯ ± s )
尺骨正向变异的原因主要有:1) 先天性尺骨发育异常致尺骨远端相对增长;2) 由于桡骨远端骨折愈合后桡骨缩短畸形或尺骨骨折后尺骨长度增加;3) 桡骨头切除术后导致桡骨相对缩短;4) 腕部旋前和用力抓握造成的动态尺骨正性变异 [
Nishiwaki等 [
治疗尺骨正向变异有非手术治疗和手术治疗两种方法。非手术治疗主要包含外用药物、口服药物、物理治疗、局部休息、局部注射药物及佩带腕产支具等方法。但非手术只能减轻症状,手术治疗是彻底治疗尺骨正向变异的唯一方法 [
尺骨远端解剖关系不复杂,没有重要神经及大血管经过,为开展尺骨手术奠定了基础。解剖上前臂尺背侧体表标志浅显,显露尺骨容易,截骨操作要求精细,尺骨远端截骨较安全,并发症较少。郭明君等 [
1) 术前仔细测量,术中要精准截骨,截骨处选择距尺骨茎突约5.0 cm,尽量不要剥离尺骨骨膜,减少术后截骨处愈合不良、延迟愈合甚至不愈合等并发症。2) 术中尺骨截骨短缩后,复位时应避免尺骨旋转和成角。3) 严重骨质疏松患者,内固定把持力不够,视为手术的禁忌症。4) 对于伴有下尺桡关节脱患者,复位后横向柯氏针固定,术后6~8周拔除柯氏针,及时进行前臂旋转功能练习,功能恢复也很满意。本组25例病人随访、回访发现,有1例患者术后功能恢复欠佳,疼痛缓解不理想,分析原因可能与患者术前存在下尺桡关节炎有关。
总而言之,尺骨横向短缩截骨治疗尺骨正向变异可明显减轻患者腕部疼痛,改善腕关节甚至上肢的功能,提高手握力,操作简单,是一种有效可行的治疗方法。但要合理选择病例,把握手术适应症及注意事项。虽然本组病例采用尺骨远端横向短缩截骨术治疗尺骨正向变异取得了良好疗效,但病例数目较少,缺乏长期随访资料,有待进一步丰富病例、延长随访时间以得到进一步验证。
黄 俊,陈 锐,金相廷,李东洋. 尺骨横向短缩截骨治疗尺骨正向变异的临床分析Clinical Analysis of Ulnar Transverse Shortening Osteotomy in Treatment of Ulnar Positive Variance[J]. 外科, 2023, 12(04): 33-40. https://doi.org/10.12677/HJS.2023.124006
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