Unyango lotyando lwe-humeral stem fractures kunye namanqaku obugcisa

Ukunciphisa ubunzima be-postoperative kufuneka kugcinwe ubuninzi bekhilogram enye de kube kuphunyezwe ukuphulukiswa okukhulu kwe-fracture (ngokuqhelekileyo iinyanga ezintathu) .I-Humeral stem fractures (HSF) ixhaphake, ibala malunga ne-1% ukuya kwi-5% yazo zonke iifractures. Isiganeko sonyaka si-13 ukuya kwi-20 kubantu be-100,000 kwaye ifunyenwe ukuba yanda kunye neminyaka yobudala. I-HSF inokusabalalisa kweminyaka yobudala be-bimodal, kunye nenqanaba lokuqala elivela kumadoda phakathi kwe-21 kunye ne-30 iminyaka yobudala emva kokutshatyalaliswa kwamandla aphezulu, ngokuqhelekileyo kubangele ukuphuka kwe-comminuted kunye nokulimala kwezicubu ezithambileyo. Incopho yesibini yenzeka kwabasetyhini abaphakathi kweminyaka engama-60 kunye nama-80 ubudala, ngokuqhelekileyo kulandela umonzakalo wamandla aphantsi.

Unyango lotyando

一. Ukulungiswa kwangaphakathi kunye nepleyiti yokubuyisela indawo

Iimpawu:

• I-Radial nerve palsy (RNP) kwi-HSF ayibonakalisi utyando kuba ihambelana nezinga eliphezulu lokubuyisela ngokukhawuleza (jonga kwakhona - Iingxaki / i-Nerve ye-Radial ngezantsi).

• Ngenye indlela, nayiphi na ingozi yokulimala kwe-vascular efuna ukulungiswa okanye i-bypass isalathisi esipheleleyo sonyango lotyando lokuphuka, njengoko ukulungiswa okuqinileyo kukhusela i-anastomosis ye-vascular.

• Kule meko, ukulungiswa kwangaphakathi kunye neplate kukhawuleza kwaye kunokwethenjelwa ngakumbi kune-IMN kuba ukulungiswa kwe-vascular kwenziwa ngendlela echanekileyo (ngokuqhelekileyo i-medial approach).

• I-HSF ene-proximal okanye i-distal intra-articular extension yenye imeko apho i-ORIF eneepleyiti iyindlela engcono.

  
  

Ukuvezwa ngotyando:

• Iifractures ezibekwe kwi-proximal kunye / okanye phakathi kwesithathu ziphathwa kusetyenziswa indlela ye-classic anterolateral.

• Xa kuyimfuneko, le ndlela yokwandiswa kude ukuze iveze yonke i-humerus.

• Nangona kunjalo, le ndlela ayikhuthazwa kwi-distal intra-articular fractures.

• Ukuqhekeka kwe-distal yesithathu ngokuqhelekileyo kuvezwa yindlela yokwahlula i-triceps.

• Kwi-distal kunye ne-middle third fractures, i-modified posterior approach echazwe nguGerwin et al30 inokutyhila i-76-94% ye-humerus (kuxhomekeke kwi-radial nerve release kunye nokukhululwa kwe-septal).

  
  

Ubuchule botyando:

• Isigulana sibekwe kwindawo yesitulo elwandle ukwenzela indlela ye-anterolateral. Ukusetyenziswa kwebrace yengalo kunceda ukugcina ulungelelwaniso lwesiqu esine-humeral. Ukuvezwa ngasemva, indawo esecaleni yindawo ekhethiweyo.

• Ukwakhiwa kwepleyiti echanekileyo iquka i-4.5 mm yentsimbi yentsimbi okanye ilingana kwaye kufuneka ifake ubuncinane ii-cortices ezi-6 ngaphezulu nangaphantsi kwendawo yokuphuka, kodwa ii-cortices ezi-8 zikhethwa.

• Xa kuyimfuneko, ukudibanisa ipleyiti encinci kunye neqhekeza elikhulu liyacetyiswa, njengecwecwe elincinci lesithathu le-tubular ukugcina i-repositioning (i-transverse fracture okanye i-butterfly fragment), eyongezwa nge-plate ye-4.5 mm emxinwa yokulungiswa kokugqibela kokuphuka.

• Kwi-distal fractures yesithathu, i-posterior lateral column preformed plate (3.5 / 4.5) inconywa ukuba ivumele ukulungiswa kwe-epiphyseal eqinile.

  
  

Ukusetyenziswa kwezikrufu zokutshixa kwi-HSF kuhlala kuyimpikiswano

• Xa uthelekisa iipleyiti zokutshixa kunye namacwecwe angavaliyo kwiifractures ezinomgangatho omhle wamathambo, akukho nzuzo ye-biomechanical kwi-torsion, ukugoba okanye ukuqina kwe-axial kuzo zombini izakhiwo.

• Ngakolunye uhlangothi, xa ujongene nomgangatho ophantsi wamathambo, ukusetyenziswa kweepleyiti zokutshixa kunokuba luncedo.

• Kuphononongo lwe-biomechanical olwenziwe nguGardner et al. ngokukodwa kwiimodeli ze-osteoporotic fracture, izakhiwo ze-34 ezingavaliyo zazizinzile kakhulu kunokutshixa okanye izakhiwo ezixubileyo.

Ukuqhekeka kwepleyiti encinci lukhetho lotyando olubonakala lubonelela ngenqanaba eliphezulu lempumelelo kunye nezinga eliphantsi lokuxakeka. Nangona kunjalo, kuphononongo olwenziwayo olubandakanya izigulane ze-76, u-van de Wall et al. ibonise ukuba uzinzo olupheleleyo lokuqhekeka kwesiqu se-humeral kukodwa lenza lifutshane kakhulu ixesha lokuphiliswa kweradiographic xa kuthelekiswa nokuzinza.

Ulawulo lwasemva kotyando:

• Ngokuqhelekileyo, ukulungiswa okuzinzileyo kufumaneka ngokusetyenziswa kwepleyiti. Ngaloo ndlela, isigulane sivumelekile ukuba senze imisebenzi esebenzayo kunye neyoncedo esebenzayo ngaphandle kokukhawulelana noluhlu lokuhamba kwegxala okanye i-elbow.

• Isilingi singasetyenziselwa iintsuku ezininzi ukulawula iintlungu.

• Ukunciphisa ubunzima be-postoperative kufuneka kugcinwe ubuninzi bekhilogram enye de kube kuphunyezwe ukuphulukiswa okukhulu kwe-fracture (ngokuqhelekileyo iinyanga ezintathu).

• Izigulane ezincinci zivumelekile ukuba zithwale ubunzima apho kuvumelekileyo (umzekelo, ukufuna iintonga zokuhamba), kodwa kwizigulane ezikhulileyo oku kufuneka kuxoxwe kwimeko nganye.

Iziphumo ezixeliweyo

• Amazinga okuphulukisa emva kokugcoba avela kwi-87% ukuya kwi-96%, kunye nexesha eliqhelekileyo lokuphulukisa kwiiveki ze-12.

• Amazinga obunzima avela kwi-5% ukuya kwi-25%, kunye neengxaki eziqhelekileyo ezingaqhelekanga ezifana nokusuleleka, i-osteonecrosis, kunye ne-malunion.

• I-RNP ephuma kunyango ngumngcipheko kwiindlela ezininzi ze-humeral stem. U-Streufert et al50 uhlolisise iimeko ze-261 ze-HSF eziphathwe nge-ORIF kwaye zafumanisa ukuba i-RNP efunyenwe ngonyango yenzeke kwi-7.1% yeendlela ze-anterolateral, i-11.7% yeendlela ezihlukeneyo ze-triceps, kunye ne-17.9% ye-triceps egciniweyo.

• Ngoko ke, kubalulekile ukuchonga nokukhusela i-nerve ye-radial kuzo zonke ii-dissections ezivulekileyo.

  
  

二. Isikhonkwane se-Intramedullary

Iimpawu:

• Ngokwethiyori, i-IMN inokubonelela ngezibonelelo ze-biomechanical kunye notyando olungaphezulu kweplating

• Ukusuka kwimbono ye-biomechanical, indawo ye-intramedullary yesixhobo ihambelana ne-axis yomatshini yesiqu se-humeral.

• Ngesi sizathu, ukufakelwa kuphantsi kwamandla aphantsi okugoba kwaye kuvumela ukwabelana ngomthwalo ongcono. Iimpawu zotyando zokubethelwa kwe-intramedullary ziyafana nezokubethelwa.

• Nangona kunjalo, njengoko kukhankanyiwe ngaphambili, ezinye iifractures zikulungele kangcono ukubethelwa kunokubethelela.

• Iimpawu zokuqhekeka kunye neepatheni eziye zafunyanwa ziphezulu kune-IMN ziyi-pathologic kunye nokuphuka okuzayo, izilonda zecandelo, kunye ne-osteoporotic fractures.

• Ukwaphuka okulula kwesiqingatha sesithathu kukwaluphawu oluhle lwe-IMN.

• Ukongeza, isikhonkwane sinokufakwa ngokusikwa okuncinci, okunciphisa ukuhluthwa kwezicubu ezithambileyo xa kuthelekiswa nobugcisa bokucwenga.

• Oku kuyinyani ngokukodwa kwiifractures zesiqingatha sesithathu se-humerus.

ubuchule botyando:

• Esona sithuba sesigulane kule nkqubo sikwisitulo esiselwandle. Ukusetyenziswa kwebrace yengalo kuluncedo kakhulu ekugcineni ulungelelwaniso lweshaft kunye nokwenza izikrufu zokutshixa ze-distal freehand.

• Inqaku lokungena lixhomekeke kuyilo lwesikhonkwane, kodwa ngokuqhelekileyo lufumaneka ekudibaneni kwe-tuberosity enkulu kunye ne-articular surface yentloko ye-humeral, oku kuthetha ukuba imisipha ye-rotator cuff kufuneka ingene.

• Kule nkqubo, kucetyiswa ukuba wenze indlela yokwahlula i-deltoid ukujonga i-tendon ye-supraspinatus.

• Enyanisweni, xa ungena kwintloko ye-humeral phakathi kwe-tendon ye-supraspinatus, umntu uya kuzifumana ephakathi kwentloko kwi-plane ye-sagittal.

• Kubalulekile ukusebenzisa i-keratomile phantsi kwe-fluoroscopy ukuqinisekisa ukuba indawo yokungena ikwimeko eyamkelekileyo kuzo zombini iindiza ze-sagittal kunye ne-coronal.

• Emva koko, ucingo lwesikhokelo kufuneka luqhubele phambili phambili ngaphambi kokuvula i-tendon ye-supraspinatus ixesha elide phantsi kombono othe ngqo.

• Isinyathelo esilandelayo sibandakanya ukuvula umsele phezu kwenaliti ye-Kirschner, ukuqinisekisa ukuba ukuphuka kulungelelaniswa ne-traction kunye / okanye ukukhwabanisa kwangaphandle, kwaye emva koko uqhubela phambili kwisikhokelo kwi-canal intramedullary ukuya kwi-elbow.

• Ukucinga kwakhona kufunyaniswe kuluncedo kwizigulana eziselula kwaye akusoloko kuyimfuneko kwizigulana ezindala.

• Ukubekwa kwe-distal bolt, ukuvala i-AP kukhuselekile kwaye kufuna indlela encinci ye-2-3 cm ukunciphisa umngcipheko wokulimala kwe-nerve ye-myocutaneous.

• Okokugqibela, i-IMN ehambelanayo iphezulu kwi-IMN yokubuyisela umva ngenxa yeengxaki ezithile zokugqibela ezibandakanya ukuphuka kwe-supracondylar zonyango, ukulahleka kwe-elbow extension, kunye ne-heterotopic ossification.

  
  

Ingqwalasela ekhethekileyo kufuneka ihlawulwe kubude besikhonkwane esikhethiweyo, njengoko izikhonkwane ezide kakhulu zinokukhokelela kwiimpazamo ezimbini zobugcisa:

• Ukuphazamiseka kwindawo yokuphuka ngexesha le-nail yempembelelo

• kunye / okanye izikhonkwane eziphuma kwindawo ye-subacromial

  
  

Kwi-helix yesithathu esondeleleneyo okanye i-oblique fractures ende, ababhali batusa indlela evulekileyo encinci yokunciphisa i-fracture elandelwa kukulungiswa kunye nentambo yocingo. Ngapha koko, kolu hlobo lwe-fracture subtype, isihlunu se-deltoid sithambekele ekubambeni iqhekeza leqhekeza elikufutshane ngelixa i-pectoralis enkulu itsala iqhekeza le-distal fracture medially, elonyusa umngcipheko wokungajongi okanye ukulibaziseka ukuphiliswa.

Ulawulo lwasemva kotyando

• Izigulane zikhuthazwa ukuba zenze ukunyakaza okusebenzayo kunye nokuncedisa ngokusebenzayo kwegxalaba kunye ne-elbow njengoko kunyamezelwa.

• Izilingi zingasetyenziselwa iintsuku ezimbalwa ukulawula intlungu.

• Izithintelo zokuphakamisa ubunzima emva kokuhlinzwa zigcinwa kwikhilogram enye kude kube yilapho ukuphulukiswa kwe-fracture kubonakala (ngokuqhelekileyo iinyanga ezintathu).

• Kwiimeko ezininzi, ukuthwala ubunzima kuvunyelwe

  
  

Iziphumo ezixeliweyo:

• Uncwadi malunga nokusetyenziswa kwezixhobo zokutshixa izikhonkwane zolawulo lwe-HSF aluhambelani. Ngakolunye uhlangothi, isantya esixeliweyo se-bone nonunion siguquguquka kakhulu (phakathi kwe-0% kunye ne-14%), kunye nesiganeko esiphezulu kwizizukulwana ezindala zezipikili. Ngakolunye uhlangothi, iziganeko zeengxaki zegxalaba (kubandakanywa intlungu, ukunyanzeliswa, ukulahlekelwa kwentshukumo okanye amandla) (ukusuka kwi-6% ukuya kwi-100%) kuye kwabikwa kwiincwadi zangaphambili.

• Inxalenye yengxaki inokuchazwa nge-subacromial trauma ngenxa yokungasebenzi kakuhle kwe-tendon ebangelwa zizikhonkwane eziphumayo, izicubu ezibomvu kunye / okanye i-rotator cuff ukulimala kule ndawo ebalulekileyo ye-isovascularity.

• Ababhali abaninzi baye bachaza iindlela ezahlukeneyo zokuphepha lo mmandla we-hypovascular kunye nokulungisa i-tendon ngendlela ehlakaniphile, ebonise amazinga aphantsi okungasebenzi kwamagxa.

  
  

Unyango olulondolozayo lwe-HSF lunikeze iziphumo ezilungileyo zokusebenza kunye namazinga aphezulu okuphulukisa ubuncinane kwi-80% yezigulane. Ngesi sizathu, ihlala ilunyango olukhethwayo kuninzi lwe-HSF. Ukuba ukulungelelaniswa akwamkelekanga, utyando kufuneka luqwalaselwe. Oku kuyinyani ngokukodwa kwizigulane ezingaphezu kweminyaka engama-55 ubudala ezibonisa ukuphuka kwe-oblique yesithathu (izinga eliphantsi lokuphilisa). Ngokuphathelele unyango lotyando, uncwadi alubonisi naziphi na iiyantlukwano ezibalulekileyo phakathi kwamacwecwe kunye ne-IMN ngokubhekiselele kumazinga okuphulukisa okanye iingxaki ze-nerve radial, kodwa iingxaki zegxalaba (ukuphazamiseka kunye nokunciphisa uluhlu lokunyakaza) kunokwenzeka ngakumbi nge-IMN. Ke ngoko, i-cuff kufuneka ilawulwe ngononophelo olukhulu kwindawo yokungena kunye nangexesha lokuvalwa.

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