Kugeza ubu, hari uburyo butandukanye bwo kuvura kuvunika kwa radiyo ya kure, nko gutunganya plaster, kugabanya gufungura no gukosora imbere, ikadiri yo gukosora hanze, nibindi. Muri byo, gukosora plaque birashobora kubona ingaruka zishimishije, ariko hariho raporo mubitabo ko ibibazo byayo biri hejuru ya 16%.Ariko, niba isahani yicyuma yatoranijwe neza, ibibazo byingutu birashobora kugabanuka neza.Uru rupapuro ruvuga muri make muri make ibiranga, ibimenyetso, imiti igabanya ubukana, hamwe nubuhanga bwo kubaga uburyo bwo kuvura plaque ya plaque ya radiyo ya kure.
1. Hariho inyungu ebyiri zingenzi zisahani yimikindo
A.Bishobora gutesha agaciro igice cyingufu zingufu.Gukosora hamwe nu mfuruka yo gukosora bifasha igice cya kure kandi ikohereza umutwaro kuri shitingi ya radiyo (Ishusho 1).Irashobora kubona infashanyo ya subchondral neza.Sisitemu ya plaque ntishobora gukosora gusa kuvunika kwimbere yimbere-arctular, ariko kandi irashobora kugarura neza imiterere ya anatomique yamagufwa yimbere-arctular igufwa binyuze mumagambo / screw "imeze nkabafana".Kubwoko bwa kure bwa radiyo yamenetse, iyi sisitemu yo hejuru itanga ituze ryiyongera ryemerera gukanguka hakiri kare.
Igicapo 1, a, nyuma yuburyo butatu bwo kwiyubaka busanzwe bwavunitse bwa radiyo ya kure, witondere urwego rwo kwikuramo dorsal;b, kugabanya kugaragara kuvunika, inenge igomba gukosorwa kandi igashyigikirwa nisahani;c, kuruhande nyuma ya DVR ikosowe, umwambi werekana kwimura imitwaro.
B. Ingaruka nke ku ngingo zoroheje: gukosora plaque ya volar iri munsi gato yumurongo wamazi, ugereranije nisahani ya dorsal, irashobora kugabanya uburakari kuri tendon, kandi hari umwanya uhari, ushobora kwirinda neza kwimikwa no gutembera.itumanaho ritaziguye.Byongeye kandi, ibyatewe byinshi birashobora gutwikirwa na quadratus.
2. Ibyerekana no kubuza kuvura radiyo ya kure hamwe na plaque ya volar
a.Ibyerekana: Kubwo kunanirwa kugabanuka gufunze kuvunika bidasanzwe-arctular, ibintu bikurikira bibaho, nko guhindagurika kwa dorsal kurenza 20 °, kwikuramo dorsal kurenza 5mm, radiyo ya kure igabanya hejuru ya 3mm, no kwimura ibice byavunitse kure kuruta 2mm;Kwimura kuvunika imbere birenze mm 2;kubera ubwinshi bwamagufwa, biroroshye gutera kongera kwimurwa, kubwibyo birakwiriye cyane kubasaza.
b.Kwirinda: gukoresha anesthetike yaho, indwara zanduza cyangwa sisitemu, indwara mbi yuruhu kuruhande rwa volar kuruhande;ubwoko bwamagufwa nubwoko bwavunitse ahavunitse, ubwoko bwavunitse bwa dorsal nko kuvunika kwa Barton, kuvunika kwa radiocarpal hamwe no gutandukana, radiyo yoroshye ya Styloid yamenetse, kuvunika kwa avulion ntoya ya volar margin.
Ku barwayi bafite ibikomere byingufu nyinshi nko kuvunika gukabije hagati yimitsi cyangwa gutakaza amagufwa akomeye, intiti nyinshi ntizisaba gukoresha plaque ya volar, kubera ko kuvunika kure cyane bikunze kwibasirwa na nérosose y'amaraso kandi bigoye kubona kugabanuka kwa anatomique.Ku barwayi bafite ibice byinshi byavunitse hamwe no kwimurwa gukomeye hamwe na osteoporose ikabije, isahani ya volar iragoye gukora neza.Hashobora kubaho ibibazo bijyanye ninkunga ya subchondral mu kuvunika kure, nko kwinjirira mu mwobo.Ubuvanganzo bwa vuba bwatangaje ko igihe imanza 42 zavunitse mu nda zifata ibyapa bya volar, nta miyoboro ya arctular yinjiye mu mwobo wa arctular, ibyo bikaba byari bifitanye isano cyane cyane n’aho isahani ihagaze.
3. Ubuhanga bwo kubaga
Abaganga benshi bakoresha plaque ya volar kugirango bavunike radiyo ya kure muburyo nubuhanga.Ariko rero, kugirango wirinde neza ko habaho ibibazo biterwa na nyuma yuburwayi, harasabwa tekinike nziza yo kubaga, urugero, kugabanuka kurashobora kuboneka mugusohora compression yumutwe wavunitse no kugarura gukomeza amagufwa ya cortique.Gukosora by'agateganyo hamwe n'insinga za Kirschner 2-3 zirashobora gukoreshwa.Kubyerekeranye nuburyo bwo gukoresha, umwanditsi arasaba PCR (flexor carpi radialis) kwagura inzira ya volar.
a, Gukosora by'agateganyo hamwe n'insinga ebyiri za Kirschner, menya ko impengamiro ya volar n'ubuso bwa arctular bitagaruwe neza muri iki gihe;
b, Umugozi wa Kirschner ukosora isahani by'agateganyo, witondere gukosora impera ya kure ya radiyo muri iki gihe (tekinike yo kuvunika ibice bya tekinike), igice cyegeranye cy'isahani gikururwa kigana ku cyuma cya radiyo kugira ngo ugarure impagarike ya volar .
C.
Ingingo z'ingenzibwo kwegera: Gutandukanya uruhu rwa kure bitangirira ku ruhu rwikiganza, kandi uburebure bwarwo bushobora kugenwa ukurikije ubwoko bwavunitse.Flexor carpi radialis tendon nicyatsi cyayo bigabanywa kure kumagufa ya karpal kandi yegeranye bishoboka.Gukurura flexor carpi radialis tendon kuruhande rwa ulnar birinda imitsi ya median na flexor tendon complex.Umwanya wa Parona uragaragara, hamwe na quadratus yerekana iri hagati ya flexor hallucis longus (ulnar) na arteriire ya radiyo (radial).Gukata byakozwe kuruhande rwa radiyo ya quadratus, hasigara igice gifatanye na radiyo kugirango nyuma yo kwiyubaka.Gukurura kwadratus kwadratus kuruhande rwa ulnar biragaragaza neza impande ya volar ulnar ya radiyo.
Kubwoko bugoye bwo kuvunika, birasabwa kurekura intera yimitsi ya brachioradialis, ishobora guhagarika gukurura kwayo kuri styloide.Muri iki gihe, icyuma cya volar cyicyiciro cya mbere cya dorsal kirashobora gutemwa kugirango kigaragaze kuvunika kure Hagarika uruhande rwa radial na styloide ya radiyo, imbere uzengurutsa uruziga rwa radiyo kugirango utandukane n’ahantu hacitse, hanyuma ukoreshe insinga za Kirschner kugirango ugabanye imbere -umwanya wo kuvunika.Kuvunika gukomeye imbere-articular, arthroscopie irashobora gukoreshwa mugufasha kugabanya, gusuzuma, no guhuza neza ibice byavunitse.
Nyuma yo kugabanuka kurangiye, plaque ya volar isanzwe ishyirwa.Isahani igomba kuba hafi y’amazi, igomba gutwikira inzira ya ulnar, kandi impera yegeranye yisahani igomba kugera hagati yumutwe wa radiyo.Niba ibintu byavuzwe haruguru bitujujwe, ingano yisahani ntabwo ikwiye, cyangwa kugabanuka ntibishimishije, imikorere iracyari nziza.
Ingorane nyinshi zifite byinshi byo gukora aho isahani ishyizwe.Niba isahani ishyizwe muburyo bukabije, ingorane zijyanye na flexor hallucis longus ziteganijwe;niba isahani ishyizwe hafi yumurongo wamazi, flexor digitorum profundus irashobora kuba mukaga.Kugabanuka kuvunika kumiterere yimiterere ya volar birashobora gutuma byoroshye icyapa cyicyuma kigana kuruhande rwa volar hanyuma ugahita uhura na flexor tendon, amaherezo biganisha kuri tendinitis cyangwa no guturika.
Ku barwayi ba osteoporotique, birasabwa ko isahani yegera umurongo w’amazi ashoboka, ariko ntibirenze.Insinga za Kirschner zirashobora gukoreshwa mugukosora subchondral yegereye ulna, kandi insinga za Kirschner kuruhande no gufunga imisumari hamwe ninshyi birashobora gukumira neza kuvunika kutongera kwimurwa.
Isahani imaze gushyirwaho neza, impera yegeranye yashyizwe hamwe na screw, kandi umwobo wa ulnar kumpera yanyuma yisahani ushyirwaho byigihe gito ninsinga ya Kirschner.Intraoperative fluoroscopy anteroposterior kureba, kureba kuruhande, kuzamura ukuboko hejuru 30 ° kureba kuruhande, kugirango umenye kugabanuka kuvunika nu mwanya wo gukosora imbere.Niba umwanya w'isahani ushimishije, ariko insinga ya Kirschner iri mu gihimba, bizatuma habaho gukira kudahagije kwimyuka ya volar, bishobora gukemurwa no gusubizaho isahani binyuze muri "tekinike yo kuvunika kure" (Ishusho 2, b).
Niba iherekejwe no kuvunika kwa dorsal na ulnar (ulnar / dorsal Die Punch) kandi ntibishobora kugabanuka rwose mugihe cyo gufunga, uburyo butatu bukurikira burashobora gukoreshwa:
1. Vuga impera yegeranye ya radiyo kugirango idakomeza kuba ahantu havunitse, hanyuma usunike kuvunika kwa fossa lunate werekeza kuri carpus ukoresheje uburyo bwo kwagura PCR;
2. Kora uduce duto kuruhande rwa dorsal igice cya 4 nicya 5 kugirango ugaragaze igice cyacitse, hanyuma ugikosore hamwe ninshundura mumwobo wa ulnar cyane wisahani.
3. Gufunga percutaneous cyangwa byibura byibasiwe no gufashwa na arthroscopie.
Nyuma yo kugabanuka birashimishije kandi isahani ishyizwe neza, gukosora byanyuma biroroshye.Niba insinga ya ulnar Kirschner ihagaze neza kandi ntamugozi uri mumyanya ihuriweho, kugabanuka kwa anatomique birashobora kuboneka.
Uburambe bwo guhitamo: Bitewe no gukomera gukabije kwamagufwa ya cortical cortical, uburebure bwa screw burashobora kugorana kubipima neza.Imiyoboro miremire irashobora gutera kurakara, kandi imigozi migufi ntishobora gushyigikira no gukosora igice cya dorsal.Kubera iyo mpamvu, umwanditsi arasaba ko hakoreshwa imigozi yo gufunga imigozi hamwe nudukingirizo twinshi two gufunga mugikorwa cya radiyo styloide hamwe nu mwobo wa ulnar cyane, no gukoresha imigozi ifunze inkoni zifunze mumwanya usigaye.Gukoresha inama idahwitse birinda kurakara bikabije nubwo gusohoka kwa dorsal byakoreshejwe.Kuburyo bwo guhuza isahani yegeranye, imigozi ibiri ihuza + umugozi umwe usanzwe (ushyizwe muri ellipse) urashobora gukoreshwa mugukosora.
4. Incamake yinyandiko yuzuye:
Gufunga imisumari ya volar gukosora ivunika rya radiyo ya kure irashobora kugera kubikorwa byiza byubuvuzi, biterwa ahanini no guhitamo ibimenyetso nubuhanga buhebuje bwo kubaga.Gukoresha ubu buryo birashobora kubona neza imikorere yimikorere hakiri kare, ariko nta tandukaniro mubikorwa byanyuma no kwerekana amashusho hamwe nubundi buryo, impanuka ziterwa na nyuma yibikorwa zirasa, kandi kugabanuka gutakara mugukosora hanze, gukosora insinga za Kirschner, no gutunganya plaster. , kwandura inshinge zanduye zirasanzwe;na extensor tendon ibibazo bikunze kugaragara muri sisitemu ya radiyo ya plaque ikosora.Ku barwayi barwaye osteoporose, plaque ya volar iracyahitamo bwa mbere.
Igihe cyo kohereza: Ukuboza-12-2022
