前臂双骨折的手术入路.ppt

尺桡骨双骨折尺桡骨双骨折 骨二科学习AP and lateral views of the both bones fracture of the forearm,demonstrating significant shortening and relatively simpleoblique fracture patterns.The patient is positioned supine with the arm prepped anddraped to just above the elbow and a tourniquet in place.This figure demonstrates the arm held in supination.Note theposition of the biceps insertion as well as the palpable tendonof the FCR and radial artery.BICEPSTENDONRADIALARTERYFLEXOR CARPIRADIALIS(FCR)A useful technique to make the skin incision is to take a bovicord and pull it taught from the radial side of the biceps tendonto the FCR at the level of the wrist.This can then be used as a template for the incision line.The incision is taken down through the skin,identifying the fascial layer with care taken not to damage any superficial veins that may be intact.The FCR tendon is clearly visible throughout the wound,as is the radial artery in the distal extent of the wound.FCRRADIALARTERYA closeup of the distal aspect of the wound demonstratingThe radial artery and its venous commtantes.RADIAL ARTERY ANDVENOUS COMMTANTESFCRRADIALARTERYThe fascia on the radial side of the flexor carpi radialis is released,exposing the deep tissue.The radial artery can be followed now throughout the entire incision.The radial artery may be taken in either direction,however,typically it is easier to take the artery to the radial side.FCRRADIALARTERYThe deep dissection is now performed between the flexor-pronator mass on the ulnar side and the artery and the mobile wad on the radial side.PRONATORFor the proximal dissection,the forearm is brought intosupination and the pronator,FDS and FDP are releasedfrom the volar aspect of the radiusFDSThe pronator is being released from the radial aspect of the radius in a subperiosteal manner.This subperiostealdissection continues distally to release the origin of thecommon flexor.After exposure of the volar aspect of the radius proximallyand distally,two clamps can be placed on the ends of thebone in order to deliver them for cleaning.FCRRADIAL ARTERYEach side of the fracture is be delivered in order to expose and clean the cortical edges.These figures demonstrate delivery of the distal fragment and acurved curette being used to clean the cortical edge.Nocleaning should be performed within the intramedullary canal,as this is healthy tissue and can be useful for the healing process.Once the fractures are completely cleaned along their cortical edges such that the fracture reduction can be visualized,the two clamps are used to reduce the fracture.If a butterfly fragment exists,it is necessary to fix this with a lag screw back to one of the fracture ends in order to realign the fracture.In the current case,the fracture is a simple pattern and is reduced by delivering the bones jointly,accentuating the deformity and then rotating and fitting the bones together with progressive compression while pushing the bones back into the wound,obtaining alignment by steric interference of one side against the other.Once the bones are held reduced,as seen in the following sequence,an appropriate dynamic compression plate is placed and held in place with a clamp.It is important that this plate must have the appropriate bend for the volar aspect of the forearm so as not to gap open the dorsal side as the plate is fixed to the bone.Thus,it should be slightly underbent with respect to the standard volar concavity.These figures demonstrate reduction of the fracture with a plateheld in place on the flat,volar aspect of the bone.Once the reduction is confirmed fixation of the plate is performedusing a compressive technique through the plate.The following sequence demonstrates using the offset drillguide to place an eccentrically drilled hole away from thefracture.The screw is placed to the point where it abutsbut is not inserted completely within the plate until it isaffixed on the other side.HOLEECCENTRICALLYILLUSTRATEDIn a similar fashion to the first screw,the second screw is placed on the opposite side of the fracture,also eccentrically away from the fracture.By compressing these two screws against the plate the fracture is translated and compressed together as shown inthe following sequence.This image demonstrates the reduced fracture,viewedfrom the volarly.This image shows that the fracture is also compressed on the oppositeside due to proper contouring of the plate.Once the radius is fixed,the ulna is approached using a standard subcutaneous longitudinal incision with the arm flexed,as seen in the next image.These images demonstrate the superficial dissection downto the fascia directly over the ulna,which is the commonfascia between the flexor carpi ulnaris and the extensor carpi ulnaris.This is divided in line with the muscles directly over the subcutaneous border of the ulna.ECUEXTENSORCARPI ULNARISFCUFLEXOR CARPI ULNARISA periosteal elevator is used to cleanthe external surface of the ulna.This is cleaned,reduced and fixed in exac