本文選題：腕關(guān)節(jié) + 月骨周圍韌帶　； 參考：《河北醫(yī)科大學(xué)》2015年碩士論文

【摘要】：目的:腕關(guān)節(jié)是一個(gè)結(jié)構(gòu)十分復(fù)雜的復(fù)合關(guān)節(jié),解剖結(jié)構(gòu)包括8塊腕骨,橈、尺骨的遠(yuǎn)端,三角纖維軟骨復(fù)合體,關(guān)節(jié)囊及諸多韌帶成分,這些結(jié)構(gòu)組成了腕中關(guān)節(jié)、橈腕關(guān)節(jié)、橈尺遠(yuǎn)側(cè)關(guān)節(jié)及腕骨間關(guān)節(jié),相互聯(lián)系、相互支持,共同維護(hù)腕關(guān)節(jié)的穩(wěn)定和運(yùn)動(dòng)功能[1]。手是人的勞動(dòng)器官,而腕關(guān)節(jié)則是手的支架和樞紐,因此腕關(guān)節(jié)常因外力作用而損傷,如骨折、關(guān)節(jié)脫位和韌帶損傷等,造成腕關(guān)節(jié)運(yùn)動(dòng)的功能障礙。在腕關(guān)節(jié)的諸多損傷當(dāng)中,月骨周圍脫位是腕關(guān)節(jié)較為嚴(yán)重的一種損傷,是指橈月、尺月關(guān)節(jié)正常,月骨周圍腕骨背側(cè)或掌側(cè)脫位。但這種疾病在臨床上較為少見,約占腕部損傷的10%左右[2],且缺乏特異性的癥狀和體征,很容易被漏診或誤診,回顧近年來(lái)的文獻(xiàn),這種疾病的早期誤診率極高,為66%~81.8%[3]。在臨床中,常常有病人由于早期得不到的診治,晚期繼而出現(xiàn)腕關(guān)節(jié)不穩(wěn)定、創(chuàng)傷性關(guān)節(jié)炎等,甚至出現(xiàn)腕骨壞死,只能進(jìn)行近排腕骨切除術(shù)的治療[4-5]。通過手術(shù)治療月骨周圍脫位來(lái)恢復(fù)腕關(guān)節(jié)的穩(wěn)定性已經(jīng)得到大多數(shù)手外科醫(yī)師的認(rèn)可,基本為切開復(fù)位內(nèi)固定的手術(shù)方法。但是手術(shù)過程中是否需要修復(fù)受損腕關(guān)節(jié)韌帶,這方面的研究較少,臨床醫(yī)生了解不明顯。本研究旨在探討在手術(shù)治療月骨周圍脫位中修復(fù)損傷韌帶的臨床療效及生物力學(xué)分析,觀察月骨周圍脫位的韌帶損傷,評(píng)估月骨周圍韌帶對(duì)腕關(guān)節(jié)穩(wěn)定性的影響,為臨床手術(shù)治療月骨周圍脫位中修復(fù)韌帶的必要性提供生物力學(xué)依據(jù)。為臨床上準(zhǔn)確的診斷、指導(dǎo)患者治療及腕關(guān)節(jié)功能恢復(fù)提供參考和依據(jù)。方法:2008年至2014年我科共收治了多名月骨周圍脫位的患者,除去一部分行腕骨摘除手術(shù)的患者外,還有7名患者采取了切開復(fù)位內(nèi)固定手術(shù)的治療,其中單純切開復(fù)位內(nèi)固定術(shù)是4例,切開復(fù)位內(nèi)固定加韌帶修復(fù)的是3例。在對(duì)這7名患者隨訪中,參考Mayo腕關(guān)節(jié)評(píng)分法評(píng)估患者的治療效果,通過對(duì)患者末次隨訪中的疼痛程度、功能狀態(tài)、活動(dòng)程度、握力等四方面進(jìn)行評(píng)定打分,四項(xiàng)評(píng)分之和即為腕關(guān)節(jié)功能評(píng)分[5-6]。術(shù)后療效根據(jù)功能評(píng)分分為四個(gè)等級(jí),90~100為優(yōu),80~90為良,60~80為可,小于60為差,對(duì)Mayo評(píng)分結(jié)果分級(jí)后通過spss統(tǒng)計(jì)學(xué)軟件采用秩轉(zhuǎn)換的非參數(shù)檢驗(yàn),根據(jù)腕關(guān)節(jié)功能的評(píng)價(jià),并隨訪兩種手術(shù)操作的結(jié)果。然后進(jìn)行生物力學(xué)實(shí)驗(yàn)。選用新鮮的9例自愿捐獻(xiàn)的上肢標(biāo)本,用自己制作的實(shí)驗(yàn)固定架固定上肢標(biāo)本,通過CSS-44020系列生物力學(xué)機(jī),使腕關(guān)節(jié)處在30°背伸、30°尺偏位置,對(duì)腕關(guān)節(jié)施加垂直負(fù)荷,速度為5N/s,當(dāng)負(fù)荷達(dá)到300N后停止加速施壓,維持負(fù)荷60秒,制作月骨周圍背側(cè)脫位的病理模型(損傷標(biāo)本)。分離和解剖出韌帶的損傷情況(舟月韌帶、月三角骨韌帶、橈腕背側(cè)韌帶、舟三角背側(cè)韌帶及腕骨間背側(cè)韌帶)。將上述的標(biāo)本脫位的腕骨及移位的骨折塊復(fù)位,再經(jīng)舟狀骨遠(yuǎn)側(cè)骨折段穿針經(jīng)近側(cè)段至月骨,經(jīng)三角骨穿針至月骨做固定,另一枚克氏針固定三角骨及舟狀骨,拍攝平片,確定復(fù)位、穿針固定無(wú)誤(即是單純克氏針修復(fù)組)。采用4號(hào)絲線間斷縫合修復(fù)上述標(biāo)本中損傷的韌帶(即為克氏針加韌帶修復(fù)組)。并按此順序分別對(duì)三組標(biāo)本進(jìn)行生物力學(xué)測(cè)試,操作CSS-44020生物力學(xué)機(jī)系統(tǒng),在月骨窩和舟骨窩放置壓敏片,使用自己制作的實(shí)驗(yàn)儀器固定上肢標(biāo)本,使腕關(guān)節(jié)在背伸30°、尺偏30°位置,對(duì)腕關(guān)節(jié)施加垂直負(fù)荷,速度為5N/s,當(dāng)負(fù)荷達(dá)到200N后停止加速施壓,維持負(fù)荷60秒,對(duì)每組標(biāo)本的壓敏片測(cè)量舟骨窩和月骨窩上的壓力載荷和應(yīng)力區(qū)。壓力敏感膜的數(shù)據(jù)得到的結(jié)果用SPSS軟件進(jìn)行統(tǒng)計(jì)學(xué)分析。結(jié)果:隨訪7例病人獲得結(jié)果,術(shù)后隨訪10~26個(gè)月(平均18個(gè)月),所有患者均為一期愈合,無(wú)感染發(fā)生,對(duì)Mayo評(píng)分結(jié)果分級(jí)后通過spss統(tǒng)計(jì)學(xué)軟件采用秩轉(zhuǎn)換的非參數(shù)檢驗(yàn),切開復(fù)位內(nèi)固定加韌帶修復(fù)術(shù)優(yōu)于僅僅切開復(fù)位內(nèi)固定術(shù)。生物力學(xué)實(shí)驗(yàn)結(jié)果:通過模擬月骨周圍脫位解剖和分離出損傷韌帶,受損韌帶以舟月韌帶,月三角骨韌帶為主。生物力學(xué)實(shí)驗(yàn)結(jié)果,月骨窩、舟骨窩所受平均壓強(qiáng)大小均為克氏針加韌帶修復(fù)組、克氏針修復(fù)組、損傷標(biāo)本組依次增大。三組標(biāo)本間兩兩比較,差異均有統(tǒng)計(jì)學(xué)意義(P0.05)。結(jié)論:腕關(guān)節(jié)月骨周圍存在復(fù)雜的韌帶結(jié)構(gòu),這些韌帶對(duì)腕關(guān)節(jié)的穩(wěn)定性和月骨的穩(wěn)定起著重要作用。損傷可引起腕關(guān)節(jié)不穩(wěn)定,在月骨周圍脫位較常見。在治療月骨周圍脫位時(shí),手術(shù)能夠緩解大多數(shù)的癥狀,并改善腕關(guān)節(jié)的活動(dòng)能力。月骨周圍脫位的治療中,單純克氏針固定不能回復(fù)腕關(guān)節(jié)的即刻穩(wěn)定性,修復(fù)月骨周圍韌帶可以有效減少腕關(guān)節(jié)內(nèi)受力,對(duì)腕關(guān)節(jié)的穩(wěn)定性起到一個(gè)重要保護(hù)作用。內(nèi)固定加修復(fù)韌帶術(shù)要優(yōu)于單純的內(nèi)固定術(shù)。
[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.

【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2015
【分類號(hào)】：R687.4

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本文編號(hào)：1868777