1、概述
Extraarticular fractures of the base of the thumb metacarpal are often displaced, with a flexion deformity and may show palmar comminution (Winterstein fracture).
第1掌骨基底关节外骨折通常移位明显,呈屈曲畸形,可伴有掌侧粉碎。
2、移位机制 Displacement due to muscle forces
The pull of the thenar muscles results in palmar flexion of the distal fragment.
骨折远端由于鱼际肌牵拉向掌侧屈曲,背侧成角
3、屈曲畸形 Flexion deformity
If the flexion deformity exceeds 30 degrees, thumb function may be impaired due to muscle imbalance. Internal fixation allows for anatomical reduction.
如果屈曲畸形超过30°,由于肌肉不平衡,将会影响拇指的功能,建议手术治疗,解剖复位。
4、掌侧粉碎导致不稳定 Instability due to palmar comminution
If standard plates are used, bone graft from the distal radius may be necessary to avoid delay in bone healing and consequent secondary displacement, or failure of fixation. Angularly stable plate fixation, using a locking compression plate (LCP), prevents secondary displacement without the need of bone grafting.
如果使用标准接骨板,建议从桡骨远端取骨进行移植修复以避免骨延迟愈合、骨折二次移位、内固定断裂。而角钢板、LCP钢板则可以不用行骨移植。
5、使用钢板间接复位 Indirect reduction with the plate
Angularly stable plate fixation in the proximal fragment allows for reduction using the plate as a lever (as described below).
使用锁定板可以作为一个杠杆来复位骨折端。
6、牵引复位 Reduction by traction
Alternatively, and especially when a conventional plate is used, reduction can be performed with axial traction on the thumb, either manually, or with help of a finger trap, and simultaneous pressure on the dorsal aspect of the diaphysis.
当使用普通钢板是,可通过纵向牵引来复位骨折端,同时在掌骨干背外侧给予压力。
7、临时固定 Preliminary stabilization
Preliminary stabilization can be achieved with an obliquely inserted K-wire.If anatomical reduction is demonstrated using image intensification, a 2 mm LCP T-plate is fixed to the dorsal aspect of the first metacarpal using standard locking techniques.
可以用克氏针完成临时固定,如果经透视复位满意,可以在掌骨背侧放置2mmLCP接骨板使用标准锁定技术。
8、钢板长度 Plate length
Cut the 2.0 mm LCP to length so that 2 screws can be fixed in the distal diaphyseal fragment.
骨折远端至少有2个可以用的孔
9、钢板塑形 Contouring of the plate
The plate has to be adapted accurately to the contour of the proximal fragment. Use bending pliers to contour the plate. Be careful to bend in between the holes by positioning the pliers over the plate holes. Alternatively, insert the threaded bolt into the plate holes to bend the plate.The bend should never go through a hole as this may damage the locking mechanism.
钢板外形应用第1掌骨基底一致,使用折弯器来对钢板塑形,也可用套筒导向器对钢板折弯,不要对一个孔进行折弯,以免钢板产生应力断裂。
10、增加轻微弯曲 Adding a slight bend
In order to prevent the screw from penetrating the joint, a slight bend is necessary. Be careful not to overbend, as there is a comminuted zone at the opposite cortex, which can not withstand compression.
为了避免螺钉穿透关节,需要对钢板进行轻微预弯,注意避免弯曲过度。
11、打入第1枚螺钉 Insertion of first screw
Mark the plane of the first carpo-metacarpal joint with a thin K-wire or a hypodermic needle. Put the plate on the dorsal aspect of the proximal fragment, with a threaded drill guide in one of the outer holes. Drilling must be parallel to the marker wire (or needle) to ensure that the screw will not penetrate the joint. Confirm using image intensification.Drill through the threaded drill guide. Remove the drill guide and measure the appropriate screw length with a depth gauge.Insert the locking screw without completely tightening it.
用克氏针或注射器针头标记第1腕掌关节,将钢板放置在第1掌骨背侧近端骨折块上,将钻头套筒平行克氏针放置以免打入关节,钻孔,测深,拧入螺钉。
12、使钢板的纵向序列于掌骨一致 Plate alignment
Align the plate along the axis of the shaft.
13、打入第2枚螺钉,
方法
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同上 Insertion of 2nd screw in the proximal fragment
Insert a second screw using the same technique. Always use a threaded drill guide when preparing for locking screws.
14、使用钢板复位 Reduction by using the plate as a lever
Pressing the plate down to the diaphyseal fragment with a periosteal elevator will automatically tilt the articular fragment into its correct position. Check the reduction of the dorsal fracture line.Confirm using image intensification.
15、拧入远端螺钉 Insertion of distal screws
Insert a screw through the most distal plate hole. This screw would normally be a standard screw, as it engages in thick cortical bone. A locking screw, using a threaded drill guide when drilling, may be inserted in osteoporotic bone, or when otherwise indicated.The second distal screw is inserted using the same technique.