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Arch Orthop Trauma Sur:前臂骨干骨折愈合后无需常规拆除钢板

2014-12-15 虎群盛 丁香园

前臂骨干骨折一般是由于直接撞击或高处摔伤所导致,其主要的治疗方法包括切开复位钢板内固定、闭合复位髓内钉固定、外支架固定或长臂石膏固定。而成人前臂骨折通常使用钢板进行固定。在前臂骨折愈合后是否拆除内固定钢板在目前还存在一定争议,拆除钢板后所需要担心的主要问题是前臂再次骨折。 为了解成人前臂骨干骨折愈合后再次骨折的危险因素,并了解拆除钢板是否会增加再次骨折的风险,中国台湾的Chi-Kuo Y

前臂骨干骨折一般是由于直接撞击或高处摔伤所导致,其主要的治疗方法包括切开复位钢板内固定、闭合复位髓内钉固定、外支架固定或长臂石膏固定。而成人前臂骨折通常使用钢板进行固定。在前臂骨折愈合后是否拆除内固定钢板在目前还存在一定争议,拆除钢板后所需要担心的主要问题是前臂再次骨折。

为了解成人前臂骨干骨折愈合后再次骨折的危险因素,并了解拆除钢板是否会增加再次骨折的风险,中国台湾的Chi-Kuo Yao医生进行了一项回顾性研究,其结果发表在2014年12月的Archives of Orthopaedic and Trauma Surgery杂志上。

作者回顾性研究2008年1月至2011年5月之间钢板内固定治疗的成人前臂骨干骨折患者,包括尺骨骨折、桡骨骨折、或尺桡骨双骨折,均采用3.5mm系统的动力加压钢板进行固定。

根据骨折愈合后是否拆除钢板将患者分为A、B两组,共有122例患者170处骨折,女性40例(64处骨折),男性82例(106处骨折)。A组为拆除钢板组,共51例患者62处骨折,按照AO分型,分别为A型53处,B型7处,C型2处。B组为保留钢板组,共71例患者108处骨折,按照AO分型,分别为A型74处,B型22处,C型12处。

A组拆除钢板患者共发生了8处再次骨折,按照AO分型,A型和B型各4例,其中女性发生了3例再次骨折,男性发生了5例再次骨折。保留钢板组患者共发生了3处骨折,均为A型骨折。两组之间在再次骨折发生率上面存在显著差异,去除钢板组要明显高于保留钢板组。

统计学分析显示再次骨折发生率与性别、年龄并无联系。发生再次骨折的患者与未发生再次骨折的患者的平均年龄分别为29.8岁和28.5岁。

去除钢板组再次骨折的患者从手术到去除内固定的平均时间为14.8个月,而没有出现骨折的患者从手术到去除内固定的平均时间为19个月,虽然发生再次骨折的患者保留内固定的时间较短,但是统计学研究并未发现再次骨折发生率与内固定保留时间之间存在联系。

A组患者中有46例钢板是在骨折愈合后去除内固定,而分析钢板去除前的最后一张X线片却发现有2例骨骼愈合存在缺损。导致再次骨折的原因均为低能量损伤(见图1、2、3),然而统计学检验并无发现再次骨折发生率与骨骼缺损之间存在联系。而B组的再次骨折均为高能量损伤。

在去除钢板组的再次骨折的骨折类型中,B型骨折的发生率要明显高于A型,而在保留钢板组的患者中,再次骨折的骨折类型并无显著差别。

通过上述研究结果,作者认为保留内固定组的患者再次骨折的发生率要明显低于拆除钢板的患者,考虑到存在较高的再次骨折发生率,因此并不建议在前臂骨干骨折愈合后常规拆除钢板内固定。以下三个因素可能会造成再次骨折的风险升高:X线片上的骨缺损、内固定在术后18个月内拆除、以及原始骨折分型为B型骨折。

图片1.jpg

图1a交通事故导致的27岁男性前臂双骨折,使用3.5mm系统动力加压钢板进行了切开复位内固定 b 内固定术后16个月X线片上骨折愈合去除内固定 c拆除内固定后3个月,由于低能量暴力而导致右前臂再次骨折(滑到导致右前臂撞击地面)d 再次使用3.5mm小DCP钢板进行固定 e 骨折获得愈合

图片2.jpg

图2交通事故导致的20岁女性前臂双骨折,AO分型B型骨折,使用3.5mm系统小的动力加压钢板进行了切开复位内固定 b 骨折获得愈合,但是存在皮质缺损,大概占直径的17%,在内固定术后12个月时拆除内固定 c拆除内固定后3个月,由于滑倒再次骨折d 再次使用进行切开复位内固定,6个月后骨折愈合

图片3.jpg

图3 40岁女性前臂双骨折,使用3.5mm系统小的动力加压钢板进行了切开复位内固定 b 在内固定术后18个月时拆除内固定,桡骨皮质缺损大概占直径的50%,由于淋浴的时候拧毛巾而导致再次骨折c再次进行切开复位内固定。骨折愈合后 d 6个月后骨折愈合功能未受影响


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    2015-09-29 siiner
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    2015-11-24 bsmagic9140
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    2015-04-12 x35042875

    患OS这个疾病的高风险人群提供干预措施以避免不良预后和机械治疗措施

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