Gabl M, Arora R, Schmidle G
Univ.-Klinik für Unfallchirurgie, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich.
Unfallchirurg. 2016 Sep;119(9):715-22. doi: 10.1007/s00113-016-0219-8.
Fractures of the distal radius are most commonly caused by hyperextension injuries of the wrist. Tensile forces and force vectors, strength of impact, bone strength and soft tissue tension create individually different fracture patterns. Metaphyseal comminution, loss of cortical support, ligament avulsion and shear fragments are defining parameters for fracture instability. The dislocation of the articular fragment follows the force vectors of the extrinsic forearm muscles bridging the joint. The goal-plan-standardized (GPS) treatment strategy has proven to be helpful in choosing the ideal individual treatment. It is based on individual patient demands on wrist function and an analysis of fracture instability in computed tomography (CT) scans. The "goal" is a realistic expectation assessed by patient and surgeon. The "plan" includes a benefit-risk analysis and selection of an appropriate treatment modality. The "standardized treatment" of surgical and follow-up treatment is based on biomechanical knowledge. Locking plate osteosynthesis aims to neutralize dislocating force vectors and to allow early active mobility. Unidirectional instability can be indirectly neutralized by palmar locking plate systems. A multidirectional instability can be addressed by multiple plating following the column theory. Distal shear and avulsion fractures may require a fragment-specific osteosynthesis approach.
桡骨远端骨折最常见的原因是腕关节的过伸损伤。拉力和力矢量、撞击强度、骨强度和软组织张力会产生各自不同的骨折类型。干骺端粉碎、皮质骨支撑丧失、韧带撕脱和剪切骨折块是骨折不稳定的决定性参数。关节骨折块的脱位遵循跨越关节的前臂外在肌肉的力矢量。目标 - 计划 - 标准化（GPS）治疗策略已被证明有助于选择理想的个体化治疗方案。它基于患者对腕关节功能的个体需求以及对计算机断层扫描（CT）扫描中骨折不稳定情况的分析。“目标”是患者和外科医生评估的现实期望。“计划”包括利弊分析和选择合适的治疗方式。手术和随访治疗的“标准化治疗”基于生物力学知识。锁定钢板内固定旨在抵消脱位力矢量并允许早期主动活动。单向不稳定可通过掌侧锁定钢板系统间接抵消。多向不稳定可根据柱理论通过多钢板固定来解决。远端剪切和撕脱骨折可能需要采用针对骨折块的内固定方法。
