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从一例尺骨干骨折内固定病例，看钢板螺钉固定的基本原则

2021-10-25 Dr. Zhang 骨科青年

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如何依据骨折类型选择合适的内固定方式？如何有效置入所选择的内固定器？

情况是这样的。
昨天呢，在某平台看到一个尺桡骨双骨折合并下尺桡关节脱位切开复位钢板内固定的帖子，楼主分享了术前术后图片（来源见水印），如下：
图片
图1 术前X线可见尺桡骨中段简单骨折，合并下尺桡关节脱位。
图片
图2 术后X线提示双切口尺桡骨钢板螺钉内固定，下尺桡关节克氏针固定。
初看术后片可见对位对线良好，但仔细看不难发现：
1.尺骨骨折存在间隙（实际间隙可能较影像片所示更宽）；
2.尺骨远近端6枚钉均为普通螺钉，钢板似乎为重建板（依桡骨钢板推测）？并非锁定加压或动力加压钢板。
后来与楼主证实，确实为普通螺钉，重建钢板固定。
图片
这不禁让我产生了疑问：简单骨折钢板桥接固定是否妥当？
这延伸出来以下两个问题：
1.如何依据骨折类型选择合适的内固定方式？
2.如何有效置入所选择的内固定器？
一、骨折类型的判断及内固定原则
按AO理念，骨折按骨折粉碎程度简单分成简单骨折与粉碎骨折两类。
简单骨折仅有两个主要骨折块，可细分为横行、斜行与螺旋形骨折。简单骨折的固定原则为追求绝对稳定的骨折，以求达到一期愈合。
粉碎骨折有三个及以上主要骨折块，可以有蝶形、螺旋形粉碎等方式，粉碎骨折无法将所有骨块坚强固定，因此固定原则为相对稳定固定，以求达到二期愈合。
绝对稳定的固定方式包括螺钉与钢板。螺钉的绝对固定为拉力螺钉，而钢板需要达到绝对稳定，可以通过以下4种途径：

  • 通过钢板动力加压（LC-DCP动力加压孔或LCP的滑动加压孔）；

  • 预先的钢板塑形（折弯）；

  • 加压器加压；

  • 通过钢板孔置入拉力螺钉加压。

需要注意的是，尽管使用LC-DCP或LCP，错误的钢板使用方式或置钉顺序，依然无法达到坚强固定目的。

因此，对于上述尺骨干骨折，理论上需要达到坚强固定的目的，但该骨折线为横行骨折，无法垂直骨折线置入拉力螺钉，只能通过钢板加压作用达到绝对稳定。

二、钢板加压作用的实现

1.LC-DCP的加压方式

图片

LC-DCP为均匀的椭圆形螺钉孔，孔边缘有一定坡度。在螺钉拧入过程中，螺钉帽相当于一个球体，在螺钉孔边缘滑动，在向下行进的过程中，钢板会相对螺钉滑动。在对侧同样拧入一枚普通螺钉时，钢板与骨块的结合体就会相对螺钉滑动，形成加压作用。
图片
图片

图片

2.LCP的固定方式

锁定加压钢板具有普通和锁定螺钉结合孔，可单独置入普通或锁定螺钉。其加压方式与LC-DCP类似。但锁定加压钢板的优势在于：

1.其稳定性不依赖于钢板本身与骨面之间的摩擦，相当于置入的外固定架的作用，对骨膜血运损伤小；

2.在实现加压后，通过锁定螺钉锁定，即维持加压作用，同时将骨折两端之间的力传导至钢板-螺钉复合体，降低了LC-DCP局部应力增大螺钉失效的风险。

理论上，锁定加压钢板只有在所有螺钉都失效、拔出的情况下，才会发生内固定失效。

图片

图片

图 锁定加压钢板示意图
对于在上述病例中使用的重建钢板，其优势在于可良好塑形，适用于解剖结构比较复杂的骨盆、髋臼等部位，属于相对稳定固定。

图片

图 重建钢板示意图。其方便塑形以适应骨折部位的不同形态。
在LCP广泛使用的现在，传统DCP使用范围越来越小。
经典尺桡骨骨折固定方式可见骨折治疗的AO原则一书：
图片

图 尺桡骨双骨折示意图（来自骨折治疗的AO原则）。可见尺骨简单骨折采用拉力螺钉与LC-DCP加压固定，桡骨粉碎骨折采用LC-DCP桥接固定。

最后，在实际临床操作中，大多数病例可能未按原则固定仍能达到骨折愈合的目的，但理解骨折固定的基本理念及原则，也许能在早期规避风险，将骨折不愈合、延迟愈合、内固定失效等可能性最小化。

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    2021-11-26 passed water

    #骨干骨折#

    0

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    2021-11-05 12498cb5m13暂无昵称

    #骨折内#

    0

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    2021-10-27 41514491@qq.com

    #内固定#

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    2022-04-09 DEXTER3148

    #尺骨#

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=1821580, encodeId=d62e18215804e, content=<a href='/topic/show?id=49c210165399' target=_blank style='color:#2F92EE;'>#骨干骨折#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=101653, encryptionId=49c210165399, topicName=骨干骨折)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdqq.qlogo.cn/qqapp/101296147/72D57F5B3E12B2BB53D6BD015D14DCD6/100, createdBy=a92e2500162, createdName=passed water, createdTime=Fri Nov 26 01:22:54 CST 2021, time=2021-11-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1821645, encodeId=31b4182164556, content=<a href='/topic/show?id=a6c91016e7d7' target=_blank style='color:#2F92EE;'>#骨折内#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=80, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=101677, encryptionId=a6c91016e7d7, topicName=骨折内)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=838d2500169, createdName=12498cb5m13暂无昵称, createdTime=Fri Nov 05 23:22:54 CST 2021, time=2021-11-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1546717, encodeId=44311546e17a8, content=<a href='/topic/show?id=2230303e266' target=_blank style='color:#2F92EE;'>#内固定#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=30372, encryptionId=2230303e266, topicName=内固定)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=4faa13929419, createdName=41514491@qq.com, createdTime=Wed Oct 27 08:22:54 CST 2021, time=2021-10-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1674734, encodeId=7bed16e473408, content=<a href='/topic/show?id=536d4e340f5' target=_blank style='color:#2F92EE;'>#尺骨#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=91, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=47340, encryptionId=536d4e340f5, topicName=尺骨)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=807e27108632, createdName=DEXTER3148, createdTime=Sat Apr 09 04:22:54 CST 2022, time=2022-04-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1064021, encodeId=7a5b106402157, content=骨折，保护好大家, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b2b82397018, createdName=12346c4dm64暂无昵称, createdTime=Tue Oct 26 10:32:39 CST 2021, time=2021-10-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1063928, encodeId=2cc9106392827, content=谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=74, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=644b2182796, createdName=1207866fm50(暂无昵称), createdTime=Mon Oct 25 23:17:50 CST 2021, time=2021-10-25, status=1, ipAttribution=)]
    2021-10-26 12346c4dm64暂无昵称

    骨折，保护好大家

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=1821580, encodeId=d62e18215804e, content=<a href='/topic/show?id=49c210165399' target=_blank style='color:#2F92EE;'>#骨干骨折#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=101653, encryptionId=49c210165399, topicName=骨干骨折)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdqq.qlogo.cn/qqapp/101296147/72D57F5B3E12B2BB53D6BD015D14DCD6/100, createdBy=a92e2500162, createdName=passed water, createdTime=Fri Nov 26 01:22:54 CST 2021, time=2021-11-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1821645, encodeId=31b4182164556, content=<a href='/topic/show?id=a6c91016e7d7' target=_blank style='color:#2F92EE;'>#骨折内#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=80, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=101677, encryptionId=a6c91016e7d7, topicName=骨折内)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=838d2500169, createdName=12498cb5m13暂无昵称, createdTime=Fri Nov 05 23:22:54 CST 2021, time=2021-11-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1546717, encodeId=44311546e17a8, content=<a href='/topic/show?id=2230303e266' target=_blank style='color:#2F92EE;'>#内固定#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=30372, encryptionId=2230303e266, topicName=内固定)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=4faa13929419, createdName=41514491@qq.com, createdTime=Wed Oct 27 08:22:54 CST 2021, time=2021-10-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1674734, encodeId=7bed16e473408, content=<a href='/topic/show?id=536d4e340f5' target=_blank style='color:#2F92EE;'>#尺骨#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=91, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=47340, encryptionId=536d4e340f5, topicName=尺骨)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=807e27108632, createdName=DEXTER3148, createdTime=Sat Apr 09 04:22:54 CST 2022, time=2022-04-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1064021, encodeId=7a5b106402157, content=骨折，保护好大家, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b2b82397018, createdName=12346c4dm64暂无昵称, createdTime=Tue Oct 26 10:32:39 CST 2021, time=2021-10-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1063928, encodeId=2cc9106392827, content=谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=74, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=644b2182796, createdName=1207866fm50(暂无昵称), createdTime=Mon Oct 25 23:17:50 CST 2021, time=2021-10-25, status=1, ipAttribution=)]
    2021-10-25 1207866fm50(暂无昵称)

    谢谢分享

    0

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