Kuvhiya kurapwa kwehumeral stem fractures uye technical point

Postoperative uremu restriction inofanira kuchengetedzwa pahupamhi kirogiramu imwe kusvikira zvakakosha kuputsika kuporeswa kwaitwa (kazhinji mwedzi mitatu) .Humeral stem fractures (HSF) inowanzoitika, inotora inenge 1% kusvika ku5% yezvose zvakaputsika. Chiitiko chegore negore ndeye 13 kusvika ku20 kune 100,000 vanhu uye yakawanikwa ichiwedzera nezera.HSF ine bimodal age distribution, neyokutanga peak inowanikwa muvarume pakati pe21 ne30 yemakore ekutevera mushure mekushungurudzika kwepamusoro-simba, kazhinji kunoguma nekuputsika kwepamusoro uye kunobatanidza kukuvara kwezvinyoro zvinyoro. Peak yechipiri inoitika muvakadzi vari pakati pe60 ne80 yemakore ezera, kazhinji vachitevera kuderera kwesimba rekukuvara.

Kuvhiya kurapwa

一. Kugadziriswa kwemukati ne incisional repositioning plate

Zviratidzo:

• Radial nerve palsy (RNP) muHSF haisi chiratidzo chekuvhiyiwa nokuti inosanganiswa nehuwandu hwekukurumidza kupora (onawo - Matambudziko / Radial Nerve pasi).

• Neimwe nzira, chero kukuvara kwevascular kunoda kugadziriswa kana kudarika chiratidzo chakakwana chekuvhiya kurapwa kwekutyoka, sezvo kugadzirisa kwakasimba kunodzivirira vascular anastomosis.

• Muchiitiko ichi, kugadziriswa kwemukati neplate kunokurumidza uye kwakavimbika kupfuura IMN nokuti kugadziriswa kwevascular kunoitwa nenzira yakananga (kazhinji nzira yepakati).

• HSF ine proximal kana distal intra-articular extension ndiyo imwe mamiriro umo ORIF ine mahwendefa iri nani sarudzo.

  
  

Kuvhiyiwa kuratidzwa:

• Kutyoka kuri muproximal uye/kana pakati petatu kunorapwa pachishandiswa classic anterolateral approach.

• Kana zvichidikanwa, nzira iyi inotambanudzirwa kure kuti iburitse humerus yese.

• Nekudaro, iyi nzira haikurudzirwe kune distal intra-articular fractures.

• Kutyoka kweyechitatu distal kunowanzo kuratidzwa ne triceps split approach.

• Kune distal uye pakati pechitatu fractures, yakagadziridzwa posterior nzira inotsanangurwa naGerwin et al30 inogona kuratidza 76-94% yehumerus (zvichienderana neradial nerve release uye septal release).

  
  

Maitiro ekuvhiya:

• Murwere anoiswa munzvimbo yebhenji chair ye anterolateral approach. Kushandiswa kwesimbi yeruoko kunobatsira kuchengetedza humeral stem alignment. Pamusana pekuratidzwa kwemashure, nzvimbo ye lateral ndiyo nzvimbo inosarudzwa.

• Yakakwana yekuvaka ndiro ine 4.5 mm simbi ndiro kana yakaenzana uye inofanira kuvhara kanenge 6 cortices kumusoro uye pasi penzvimbo yekuputsika, asi 8 cortices inosarudzwa.

• Kana zvichidikanwa, kusanganiswa kwediki uye hombe chidimbu chendiro inokurudzirwa, senge pfupi yechitatu tubular ndiro kuchengetedza repositioning (inochinjika fracture kana butterfly fragment), iyo inozowedzerwa neyakamanikana 4.5 mm ndiro yekugadzika kwekupedzisira kwekutyoka.

• Kune distal yechitatu fractures, posterior lateral column preformed plate (3.5 / 4.5) inokurudzirwa kubvumira yakasimba epiphyseal fixation.

  
  

Kushandiswa kwekuvhara screws muHSF kunoramba kune gakava

• Kana uchienzanisa mahwendefa ekuvhara neasina-kukiya mahwendefa ezvimedu zvakaputsika zvine kunaka kwebhonzo, hapana biomechanical mukana mutorsion, kukotama kana kuomarara kweaxial kune ese ari maviri maumbirwo.

• Kune rumwe rutivi, kana uchitarisana nehurombo husina kunaka hwemapfupa, kushandiswa kwemahwendefa ekuvhara kunogona kubatsira.

• Muchidzidzo chebiomechanical chakaitwa naGardner et al. kunyanya kune osteoporotic fracture models, 34 isina-kukiya zvivakwa zvaive zvakanyanya kugadzikana pane kukiya kana hybrid zvimiro.

Minimally invasive plate splicing isarudzo yekuvhiya inoita seinopa budiriro yepamusoro uye yakaderera complication rate. Zvisinei, mune chidzidzo chekare chinosanganisira varwere ve76, van de Wall et al. yakaratidza kuti kugadzikana kwakakwana kwehumeral stem fractures chete inopfupisa radiographic kuporesa nguva kana ichienzaniswa nekugadzikana.

Postoperative management:

• Kazhinji, kugadziriswa kwakagadzikana kunowanikwa nekushandiswa kweplate. Nokudaro, murwere anobvumirwa kuita mabasa anoshanda uye anoshingaira-anobatsira pasina kuderedzwa nehuwandu hwekufamba kwefudzi kana gokora.

• Chipfuramabwe chinogona kushandiswa kwemazuva akati wandei kugadzirisa marwadzo.

• Postoperative uremu restriction inofanira kuchengetedzwa painodarika kirogiramu imwe chete kusvika kupora kwakakosha kwekutyoka kwaitwa (kazhinji mwedzi mitatu).

• Varwere vadiki vanobvumirwa kutakura uremu pazvinobvumidzwa (semuenzaniso, zvinoda madondoro kuti afambe), asi muvarwere vakura izvi zvinofanirwa kukurukurwa pane imwe nyaya-ne-case hwaro.

Zvabuda zvakashumwa

• Kupodza mitengo mushure mekuputira kubva ku87% kusvika ku96%, ine nguva yekuporesa yevhiki gumi nemaviri.

• Matambudziko ehuwandu anotangira kubva pa5% kusvika ku25%, ane zvinowanzoitika zvisingatarisirwi matambudziko akadai sehutachiona, osteonecrosis, uye malunion.

• RNP inotorwa mune zvekurapa injodzi kune dzakawanda humeral stem nzira. Streufert et al50 vakaongorora zviitiko zve261 zveHSF zvakabatwa neORIF uye vakawana kuti RNP yakagadzirwa nemishonga yakaitika mu7.1% yeanterolateral nzira, 11.7% yenzira dzakaparadzana dzetriceps, uye 17.9% ye triceps yakachengetedzwa.

• Naizvozvo, zvakakosha kuziva uye kudzivirira iyo radial nerve mune ese akavhurika dissections.

  
  

二. Intramedullary chipikiri

Zviratidzo:

• Theoretically, IMN inogona kupa biomechanical uye yekuvhiya mabhenefiti ari pamusoro peplating

• Kubva pakuona kwebiomechanical, iyo intramedullary chinzvimbo chemudziyo inopindirana neiyo mechanical axis yehumeral stem.

• Nechikonzero ichi, iyo implant inoiswa pasi pesimba rekukotama uye inobvumira zviri nani kugovana mitoro. Zviratidzo zvekuvhiya zve intramedullary nailing zvakafanana nezve plating.

• Nekudaro, sezvambotaurwa, mamwe mafractures anokodzera zvirinani plating pane kurovera.

• Kutyoka maitiro uye mapatani akawanikwa akakwirira kune IMN ane pathologic uye ari kuuya kuputsika, segmental maronda, uye osteoporotic fractures.

• Yakareruka yepakati-yechitatu yakachinjika mafractures zvakare akanaka zviratidzo zveIMN.

• Pamusoro pezvo, chipikiri chinogona kupinzwa kuburikidza nekachekwa kadiki, izvo zvinoderedza kubviswa kwenyama yakapfava kana ichienzaniswa nehunyanzvi hwekuisa.

• Izvi ndezvechokwadi kunyanya kune kuputsika kwepakati pechitatu chehumerus.

Kuvhiya nzira:

• Nzvimbo yemurwere yakakwana yeiyi nzira iri pachigaro chemahombekombe. Iko kushandiswa kwesimbi yeruoko kunobatsira zvakanyanya mukuchengetedza shaft alignment pamwe nekuita distal freehand locking screws.

• Iyo poindi yekupinda inoenderana nekugadzirwa kwembambo, asi kazhinji inowanikwa panosangana hutubhu yakakura uye articular pamusoro wehumeral musoro, izvo zvinoreva kuti inotenderera cuff tsandanyama inofanirwa kupindwa.

• Kune iyi nzira, zvinokurudzirwa kuita deltoid division nzira yekuona iyo supraspinatus tendon.

• Kutaura zvazviri, paunopinda mumusoro wehumeral pakati pe supraspinatus tendon, mumwe achazviwana ari pakati pemusoro mu sagittal ndege.

• Zvakakosha kushandisa keratomile pasi pe fluoroscopy kuti uone kuti nzvimbo yekupinda iri munzvimbo inogamuchirwa mune zvose sagittal uye coronal ndege.

• Mushure meizvi, tambo yekufambisa inofanira kufambiswa mberi mberi isati yavhura supraspinatus tendon kureba pasi pechiratidzo chakananga.

• Danho rinotevera rinosanganisira kuvhura mugero pamusoro petsono yeKirschner, kuve nechokwadi chekuti kuputsika kwakabatana nekukwevera uye / kana kunyengedza kwekunze, uyezve kufambisira mberi mutungamiriri mu intramedullary canal kusvika kugokora.

• Kurangarira kwakawanikwa kunobatsira muvarwere vadiki uye kwete nguva dzose kudikanwa muvarwere vakura.

• Kuti uise distal bhaudhi, kuvhara kweAP kwakachengeteka uye kunoda diki 2-3 cm nzira yekudzikisa njodzi yekukuvara kwemyocutaneous nerve.

• Chekupedzisira, kufanana kweIMN kwakakwirira kudzoreredza IMN nekuda kwematambudziko chaiwo ekupedzisira anosanganisira nemishonga induced supracondylar fractures, kurasikirwa nekuwedzerwa kwegokora, uye heterotopic ossification.

  
  

Kunyanya kutarisisa kunoda kubhadharwa kune kureba kwembambo yakasarudzwa, sezvo zvipikiri zvakarebesa zvinogona kutungamira kune mbiri zvikanganiso zvehunyanzvi:

• Kuvhiringidza panzvimbo yekutyoka panguva yekukanganisa chipikiri

• uye/kana zvipikiri zvinobuda muchikamu che subacromial

  
  

Kune proximal yechitatu helix kana kureba oblique fractures, vanyori vanokurudzira miniature yakazaruka nzira yekudzikisa kutyora kunoteverwa nekugadzirisa ne ring tie waya. Muchokwadi, kune iyi fracture subtype, mhasuru ye deltoid inotapa kubvuta chidimbu chakatyoka uku iyo pectoralis huru ichikwevera iyo distal fracture fragment nepakati, izvo zvinowedzera njodzi ye osseous nonunion kana kunonoka kuporesa.

Postoperative management

• Varwere vanokurudzirwa kuita kushingaira uye kushanda-kubatsirwa mafambiro epafudzi negokora sezvinobvumirwa.

• Slings inogona kushandiswa kwemazuva mashoma kudzora marwadzo.

• Zvirambidzo zvekusimudza uremu mushure mekushanda zvinochengetwa pachiyero chekirogiramu imwe chete kusvika kupora kwekutyoka kuchionekwa (kazhinji mwedzi mitatu).

• Muzviitiko zvakawanda, kutakura uremu kunobvumirwa

  
  

Zvakaburitswa zvawanikwa:

• Zvinyorwa pamusoro pekushandiswa kwekuvhara zvipikiri zvekugadzirisa kweHSF hazvienderani. Kune rumwe rutivi, chiyero chakashumwa chepfupa chisingaiti chinoshanduka zvikuru (pakati pe0% ne14%), ine chiitiko chepamusoro muzvizvarwa zvekare zvezvipikiri. Kune rumwe rutivi, chiitiko chezvinetso zvepafudzi (kusanganisira kurwadziwa, kupindira, kurasikirwa kwekufamba kana simba) (kubva ku6% kusvika ku100%) zvakataurwa mumabhuku apfuura.

• Chikamu chedambudziko chinogona kutsanangurwa ne subacromial trauma nekuda kwekusagadzikana kwetendon kusagadzikana kunokonzerwa nezvipikiri zvakabuda, mavanga mavanga uye / kana rotator cuff kukuvara munzvimbo ino yakakosha ye isovascularity.

• Vanyori vanoverengeka vakatsanangura nzira dzakasiyana dzekudzivisa iyi hypovascular nharaunda uye kugadzirisa tendon nenzira yakangwara, iyo yakaratidza kuderera kwemaitiro epafudzi.

  
  

Conservative kurapwa kweHSF kwakapa mhedzisiro inoshanda uye yakakwirira kuporesa mitengo mune inokwana 80% yevarwere. Nechikonzero ichi, inoramba iri kurapwa kwesarudzo kune vazhinji HSF. Kana kurongeka kusingabvumirwi, kuvhiyiwa kunofanira kufungwa. Izvi zvinonyanya kuitika kune varwere vanopfuura makore makumi mashanu neshanu vanouya neproximal yechitatu oblique fracture (yakaderera kuporesa mwero). Nezvekurapa kwekuvhiya, mabhuku haaratidze chero misiyano yakakosha pakati pemahwendefa uye IMN maererano nemitengo yekuporesa kana radial nerve complications, asi matambudziko epafudzi (kuvharirwa uye kuderedzwa kwekufamba) kunowanzoitika neIMN. Naizvozvo, iyo cuff inofanirwa kutarisirwa nekuchenjerera zvese panguva yekupinda uye panguva yekuvhara.

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