Soubeyrand Marc, Biau David, Mansour Cesar, Mahjoub Sabri, Molina Veronique, Gagey Olivier
Department of Orthopaedic Surgery, Hôpital Universitaire de Bicetre, Le Kremlin-Bicetre, France.
J Hand Surg Am. 2009 Dec;34(10):1838-44. doi: 10.1016/j.jhsa.2009.07.012.
Percutaneous screw fixation (PSF) is widely used to treat acute nondisplaced scaphoid waist fractures. PSF can be performed through a volar or dorsal approach. The aim of our study was to compare a dorsal versus volar surgical approach for PSF according to the sagittal orientation of the waist fracture (B1 or B2 in Herbert and Fisher's classification scheme, in which B1 and B2 designate, respectively, oblique and transverse nondisplaced scaphoid waist fractures) on computer modeling of cadaver wrists.
We used 12 upper limbs, and for each wrist we performed 3 computed tomography scans in maximal flexion, neutral position, and maximal extension. For each position, a parasagittal slice corresponding to the plane of ideal screw placement was obtained by numerical reconstruction. On each slice, we modeled B1- and B2-type fractures and the placement of the corresponding screws (S1 and S2) inserted through a volar or dorsal approach. Optimal screw orientation was perpendicular to the fracture. For each configuration, we measured the angle between the S1 screw and B1 fracture, which we designated V1 when modeling volar PSF and D1 when modeling dorsal PSF. Similarly, we measured angles V2 and D2.
For B2 fractures, virtual screw placement perpendicular to the fracture was achieved equally well with the 2 approaches. For B1 fractures, the virtual screw could not be placed perpendicular to the fracture with either approach, but the dorsal approach with maximal wrist flexion allowed the best screw placement.
For B2 fractures, the dorsal and volar approaches allow optimal virtual screw placement, and the choice of the approach depends on the surgeon's preference. For B1 fractures, we recommend the dorsal approach.
经皮螺钉固定术（PSF）广泛应用于治疗急性无移位舟状骨腰部骨折。PSF可通过掌侧或背侧入路进行。我们研究的目的是在尸体腕关节计算机模型上，根据腰部骨折的矢状位方向（Herbert和Fisher分类方案中的B1或B2，其中B1和B2分别表示斜形和横行无移位舟状骨腰部骨折），比较PSF的背侧与掌侧手术入路。
我们使用了12条上肢，对于每个腕关节，我们在最大屈曲位、中立位和最大伸展位进行了3次计算机断层扫描。对于每个位置，通过数值重建获得与理想螺钉置入平面相对应的矢状旁切片。在每个切片上，我们模拟了B1型和B2型骨折以及通过掌侧或背侧入路置入的相应螺钉（S1和S2）。最佳螺钉方向垂直于骨折线。对于每种配置，我们测量了S1螺钉与B1骨折之间的角度，在模拟掌侧PSF时将其指定为V1，在模拟背侧PSF时指定为D1。同样，我们测量了角度V2和D2。
对于B2骨折，两种入路均能同样良好地实现垂直于骨折线的虚拟螺钉置入。对于B1骨折，两种入路均无法将虚拟螺钉垂直于骨折线置入，但最大腕关节屈曲位的背侧入路能实现最佳螺钉置入。
对于B2骨折，背侧和掌侧入路均能实现最佳虚拟螺钉置入，入路的选择取决于外科医生的偏好。对于B1骨折，我们推荐背侧入路。
