Beck John D, Harness Neil G, Spencer Hillard T
Department of Orthopaedic Surgery, Kaiser Permanente Orange County, Anaheim, CA.
Department of Orthopaedic Surgery, Kaiser Permanente Orange County, Anaheim, CA.
J Hand Surg Am. 2014 Apr;39(4):670-8. doi: 10.1016/j.jhsa.2014.01.006. Epub 2014 Mar 6.
To determine the percentage of AO B3 distal radius fractures that lose reduction after operative fixation and to see whether fracture morphology, patient factors, or fixation methods predict failure. We hypothesized that initial fracture displacement, amount of lunate facet available for fixation, plate position, and screw fixation would be significant risk factors for loss of reduction.
A prospective, observational review was conducted of 51 patients (52 fractures) with AO B3 (volar shearing) distal radius fractures treated operatively between January 2007 and June 2012. We reviewed a prospective distal radius registry to determine demographic data, medical comorbidities, and physical examination findings. Radiographs were evaluated for AO classification, loss of reduction, length of volar cortex available for fixation, and adequacy of stabilization of the lunate facet fragment with a volar plate. Preoperative data were compared between patients who maintained radiographic alignment and those with loss of reduction. A multivariate logistic regression analysis was completed to determine significant predictors of loss of reduction.
Volar shearing fractures with separate scaphoid and lunate facet fragments (AO B3.3), preoperative lunate subsidence distance, and length of volar cortex available for fixation were significant predictors for loss of reduction; the latter was significant in multivariate analysis. Plate position and number of screws used to stabilize the lunate facet were not statistically different between groups.
Patients with AO B3.3 fractures with less than 15 mm of lunate facet available for fixation, or greater than 5 mm of initial lunate subsidence, are at risk for failure even if a volar plate is properly placed. In these cases, we recommend additional fixation to maintain reduction of the small volar lunate facet fracture fragments in the form of plate extensions, pins, wires, suture, wire forms, or mini screws.
TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.
确定AO B3型桡骨远端骨折手术固定后复位丢失的百分比，并观察骨折形态、患者因素或固定方法是否可预测失败情况。我们假设初始骨折移位、可用于固定的月骨小关节面数量、钢板位置和螺钉固定是复位丢失的重要危险因素。
对2007年1月至2012年6月间接受手术治疗的51例（52处骨折）AO B3型（掌侧剪切型）桡骨远端骨折患者进行前瞻性观察性研究。我们查阅了一个前瞻性桡骨远端数据库，以确定人口统计学数据、内科合并症和体格检查结果。对X线片进行评估，以确定AO分类、复位丢失情况、可用于固定的掌侧皮质长度，以及通过掌侧钢板固定月骨小关节面碎片的稳定性。比较维持X线对位的患者和发生复位丢失的患者的术前数据。完成多因素逻辑回归分析，以确定复位丢失的重要预测因素。
伴有舟骨和月骨小关节面分离碎片的掌侧剪切骨折（AO B3.3）、术前月骨下沉距离以及可用于固定的掌侧皮质长度是复位丢失的重要预测因素；后者在多因素分析中具有显著性。两组之间钢板位置和用于固定月骨小关节面的螺钉数量在统计学上无差异。
对于AO B3.3型骨折，若可用于固定的月骨小关节面小于15 mm，或初始月骨下沉大于5 mm，即使掌侧钢板放置正确，仍有失败风险。在这些情况下，我们建议采用钢板延长、克氏针、钢丝、缝线、钢丝成型或微型螺钉等形式进行额外固定，以维持掌侧月骨小关节面骨折小碎片的复位。
研究类型/证据水平：治疗性III级。
