Tibial Fractures, Suprapetellar intradellary Njira

Intradellallary mitu yolumikizira ma tibial fractures: kudzera pa suprapatellar, njira yoyeserera ndi bondo losinthika pa 20-30 ° ndi chubu china choteteza kuti muteteze nyumba zamisala.

01.Tibial intradellary mitaing: Kufikira ndi kuphatikizika, kupweteka kwa bondo

Kulandila kwa Entradellary kukalambira kwa tibial ndikofunikira kuti akhazikitse mitambo yolowera

Njira zapamwamba za Tibial stem zowonera ndi inrapelllar kapena parapatellar njira. Ngakhale njira izi zikuwonetsedwa kwa midy fractures, chrugus, choyipa, kapena choletsa matenda a syndesmotic nthawi zambiri chimachitika mu proximal.

Choyambitsa chachikulu cha ma alalimel mu promximal fracratures ndikuwonongeka chifukwa cha kukoka kwa quadxice ndi mikangano yamagetsi pakati pa nsonga ya tibial cortex panthawi yolowera. Patella imalepheretsanso kulowa mkati mwa msomali mu sugittal ndege (mkuyu. 1A, b). Chifukwa chake, njira inanso yolowera polowera poyambira parapatellar, yomwe imapangitsa kuti mkati mwa mitambo yolingizira mitail (nkhuyu. 1c ndi 2). Monga msomali umalowera kusokonekera kwa intravelallary kuwonongeka kwa kuwonongeka kwa kuwonongeka, gawo lolowera limakhazikika mu exhostosi (mkuyu. 2). Pomaliza, kusokonezeka kwa minofu ya anior mungu kumathandizira pang'ono kwa ectuloion (mkuyu. 3).

Chithunzi 1 A, B pogwiritsa ntchito njira yomwe ili yachilendo, patella imalepheretsa kulowa mkati mwa msomali, zomwe zimapangitsa kuti zikhale zofanana kwambiri ndi apictor a Apictor Apical .C intradellallary njira yofikira parapatellara.

Chithunzi 2 Kuyandikira Polowera Polowera pakatikatikatikatikatikatikati pang'ono kumabweretsa ma media pang'ono kulowera mitayeli. Monga msomali umalowera kusanja kwa canlal kusokonekera kwa fractal (a), gawo la proxalimal limakhazikika mu flare (b)

Mkuyu. 3 Kupumula kwa minofu ya minofu ya anior (a) kumapangitsa chidwi cha ectopic (b)

Kusanja kwa TiBA kukhala malo ochulukirapo kumathandiza kupewa zovuta zomwe zimakhudzana ndi bondo bondo bondo flexion.chesiquiquitined boot flexion. Njira yomwe idafotokozedwera ndi gelbke, Jakma et al. Mu 2010 ndipo wakhala wotchuka m'zaka zaposachedwa chifukwa kupatsa tiil tibia pamzera wowongoka kowongoka kamasinthira kupusitsa ndikukonzanso. Fluoroscopy wasanduka mwamwano kuchita. Nthawi ya fluoroscopy ya pentipatellar mitaing idanenedwa kuti ikhale yofupikira kwambiri kuposa mitsuko ya infrapether. Kuphatikiza apo, kuphatikizika kwa msomali (mu ndege ya sagitle) kumafanana kwambiri kwa axis yayitali ndi njirayi kuposa njira yolumikizira; Izi zimalepheretsa kusamvana mwamakina pakati pa nsonga ya msomali ndi corterrour cortex, potero otsogolera kuchepetsedwa.

Kupweteka kwa bondo pansi ndi vuto loyenera. Kupweteka kwa bondo lakunja kwanenedwa mu 50-70% ya odwala omwe ali ndi matenda ovala, omwe ali ndi zaka 30% okha omwe akukumana ndi zowawa pambuyo pochotsa zipilala. Kupanga kolumikizana ndi zokhudzana ndi patellar tendon ndi matope a hoffa afananizo kuti akhale gwero la bondo la bondo. Kuphatikiza apo, njira ya suprapethelar imapewera chikhalidwe cha kuwononga nthambi yamitsempha ya patenous, yomwe imapewa kunenepa kwambiri (Chithunzi 4). Popereka msomali kudzera mu tendon, motero kusiya tentur tentun yolimba, imawoneka kuti ingachepetse kwambiri momwe mabowo amakhudzidwe.

Mkuyu. 4 Pakatikati pa mitsempha ya sapnous ndi mitundu yosiyanasiyana ku TiBucual assiqua msomali

Chifukwa cha zotsatira zabwino za zotupa za proximal, zisonyezo muzochita zachipatala zakwaniritsidwa kwa onse.

Mavuto omwe angathe ndi intradellary amalowetsa mu njira ya suprapatellar:

- Titha kusiya zinyalala mu bondo. Komabe, zochitika zamankhwala zokhala ndi ma retrog atchentsolat sizinasonyeze zotsatira zake kwakanthawi.

- Kodi kuwonongeka kumachotsedwa bwanji pambuyo pakuchiritsa? Ngakhale kuti ndizotheka kuti muchotse msomali wa intravedillal, njirayi ikufunika ndipo opaleshoni yambiri amakonda kuchotsa msomali wa intramidellar njira yofikira.

02.Pin iyenera kukhala intrapathellar msomali iyenera kugwiritsidwa ntchito?

Ubwino

- Maondo okwanira bondo amathandizira kupusitsa komanso kuchepetsa minofu yopumula ndikusungirako pakati pa misomali.

- chiopsezo chotsika cha zolemba za proximal ya proximal, chopindika, komanso kuwonongeka kwamphamvu poyerekeza ndi njira zachikhalidwe

- Kusanjana ndi nthawi yovuta kuchita

- Kusanjana kumakhala kotheka ngati 'Mndandanda wa Opaleshoni Yopanda Ntchito '.

- Kuchepetsa fluoroscopy nthawi

- Palibe kuwonongeka kwa tentlir tendon komanso kuchepa kwamphamvu kwa positi

- zosavuta kugwira ntchito yamagulu angapo, monga ndi polytrauma.

Zovuta

- chiopsezo chowonongeka kuti chiwonongeke cartilage ndi zida zina za intra

- chiopsezo chowonjezereka cha matenda a bondo

- Kuchotsa kulowera kungafune njira ina

Umboni

- Zowonjezera-zowonjezera za proximal tibia (mtundu AO 41a)

- Kusavuta kwa ma taxial diaphysis (mtundu AO 42a-c)

- Gawo la Tibral Tibraal Diaphys Fracture (mtundu AO 42c)

- Kuchulukitsa kwamphamvu kwa intra-articular yolimba ya TIBIA (mitundu AO 43a ndi C1)

- bondo loyandama

Kutsutsana

- Gustilo kalasi 3c yotseguka ya tibia chifukwa cha chiopsezo chophatikizika, ngakhale chiopsezo chowonjezereka cha matenda ophatikizika sichinanenedwe

- zofewa zofewa kwambiri minofu, kuipitsidwa kapena matenda mu gawo la suprapatellar

- ipsilateral bolot prostathesis (contraindication)

- bondo

- bondo hyperrensinsity> 20 °

- Ipsilalateral Tibial Plateau Fracture yokhudza mutu wa msomali ndi gawo lotsutsana

- Zoyimira zimalepheretsa malo a msomali

- Ipsilateral patella fracture (contraindication)

03. Njira zopangira opaleshoni

Maganizo a thupi komanso malingaliro

Mpu. Miyendo yovunda imasiyidwa momasuka komanso mpukutu zimayikidwa pansi pa bondo (a) kuti mukwaniritse 10-30 ° mabondo 

(b). C-DIM imayikidwa mbali inayo. Mphuno yosavomerezeka imatsitsa 10-30 ° kuchokera pansi poti awonetsetse zoyenerera zofananira.

②Find mfundo yoyenera yolowera

Chithunzi 6 Njira iyi imadziwika ndi shaft ya patella, tibial tiketo, ndi tibial tibial cortex. Chiwopsezo cha 2 cm chimapangidwa ndi chisoti chimodzi cha 1-1.5 cm chofalikira pamutu wapamwamba kwambiri wa patella. Tendon ya quadriceps imawululidwa ndipo midzi yozungulira imapangidwa motsogozedwa ndi tendon. TruntPatellar reccent imatsegulidwa ndipo zala za opaleshoni ya Opaleshoni ikani pobowo khoma kuchokera pansi pa patella kuti muwunikenso kuti mupeze. Kuchulukitsa pang'ono kwa miyendo kungapangitse mwayi wopita ku bondo. Kuyika ma recractor a Langunbeck kuti akweze pang'ono patella pamwamba pa matella amathanso kupeza mwayi. Ngati malo olumikizirana ndi operewera kwambiri ndipo amalimbikitsa, media kapena gulu lolinganiza lingakhale lokhazikika kwa icho - sinthani kumbali imodzi.

③vertection ya cartilage

Chithunzi 7 chitetezo cha carlelofemel pachiwopsezo cha opaleshoni ndi chimodzi mwazolinga zazikulu za opaleshoni. Chifukwa chake, masikono oteteza amayenera kugwiritsidwa ntchito panthawi ya mayiyo ndi misomali yanyumba. Singano ya a Trucar imasonkhana ndi chotchingira chotchinga ndi kuyika chogwirizira.b okwera chogwiritsira ntchito mabowo am'mawa. Khomo pamwamba pa chogwirizira chimalepheretsa mwangozi pa msonkhano wa wogwira

④ Ikani chiwongolero ndikusintha udindo

Chithunzi 8A msonkhano wogwira ntchito umayikidwa pansi pa patella kudzera pa tetelofomping point yomwe mukufuna ku Tibia (Chithunzi 9). Nthawi zambiri, patella imasunthira mosamala pang'ono kapena pambuyo pake panthawi ya chida. Proove mu patelofomm yolumikizira nthawi zambiri imatsogolera singano ya trocar ku malo oyenera okha.

Mkuyu. 8b udindo wawo udatsimikiziridwa mu ndege zonse pogwiritsa ntchito fluoroscopy ndikuwongolera komwe kuyenera. Singano ya Trucar imasinthidwa ndi kuwongolera koopsa, kuwongolera komwe kumadutsa pakati pa bwalo lazowongolera ndipo omwe nsonga yake imayikidwa mu proximal tibial metaphysis kuti muwonetsetse malo oyenera.

Chithunzi 8C pomwe wowongolera ali m'malo ovuta, gulu lachiwiri lingagwiritsidwe ntchito poyendetsa ndege yabwino kudzera mwamphamvu, mpaka panjira inayake ndikuyika mopanda malire. Chida cholowera ndi bizinesiyo imayamba kuyendayenda.

⑤ Kukula kwa medullatatatata

Mkuyu. Mu ndege ya anteroproster, iyi ndi gawo limodzi mwazomwezi. Mu ndege yofananira ndi ndege, malo olowera molondola amapezeka pa kusintha kwapakati pa mawonekedwe a articular ndi athertex.

Mkuyu Wotsogolera umakonda kusuntha pompoto.

Chithunzi 9C pamilandu pomwe pini kapena msomali sizingaikidwe molondola, kutseka msomali kapena pini imathandizira kuwongolera msomali pamalo oyenera. 

Kutsetserera misomali kumagwiritsidwa ntchito m'chigawo cha fanizo pomwe ganyu kapena msomali sangathe kufanana ndi mafupa a fupa kapena pomwe ndege zowonongeka mu ndege imodzi kapena zonsezi zimakhalabe mkati mwa misozi imodzi.

Chithunzi 10 Pakadali pano, tikulimbikitsidwa kuti msonkhano wogwirizira utetezedwe ku Chingwe chogwiritsa ntchito waya wa 3.2 mm. Izi zimalepheretsa msonkhano kuti utuluke ku Tibia.

Chithunzi 11.0 mm Kubowola pang'ono kumayikidwa kudzera mu malaya amkati ndi pansi mpaka pamafupa. Camellary Callury amatsegulidwa ndikubowola mpaka kukula kwa 8-10 masentimita ndi malo owongolera mpira amaikidwa mu proximal tibia.

Kuchepetsa

Chithunzi 12A Pakadali pano, timakonzanso kuwonongeka.

Chithunzi 12b kutengera komwe kuli kusokonekera ndi morphology, zida zochepetsetsa monga zipilala zokhala ndi zigawo zambiri, zoletsa zazing'ono, komanso zomata zitha kugwiritsidwa ntchito kukwaniritsa bwino. Mu Kuchepetsa kwa Proximal kuchepetsedwa, nthawi zina ngakhale mothandizidwa ndi zowonjezera, musanatsegule Cantory Caltal mwakubowo. Ndodo yokonzekera imayendayenda kuderalo ndikuyiyika pakatikati pa faibial Tibralsys. Pambuyo pokonzanso, kutalika ndi mainchenti a msomali amatsimikizika. Ngati ndi kotheka, kukulitsa ngalande yamiyala yomwe mukufuna pokonzanso mu zowonjezera za 0,5 mm. Kutseguka mu chovala chotetezera kumalola kutulutsa zinyalala ndikuyamwa zinyalala kuchokera pakulowa kolumikizidwa. Ngati ndi kotheka, tikulimbikitsidwa kuti msomali wokhala ndi mainchesi osachepera 10 mm. Awo 5.0 mm Kutseka kwamitundu iyi ya msomali kumakhala kovuta kwambiri kuposa mpweya wa 4.0 mm womwe umagwiritsidwa ntchito m'misomali ya FRARS. Kutalika kwa misomali ya intradellary nthawi zambiri kumatsimikiziridwa ndi wolamulira wa fluoroscopic.

⑦ant intradellallary msomali

Mkuyu. 13A mitayi imayika ndodo yokonzanso pansi pa fluoroscopy. Dziwani kuti kulowetsa msomali wa suprapatellar ndikotalikirana ndi msomali wa infrapatellar chifukwa cha pakhungu polowera kwa tibial msomali ndi nthawi yayitali.

Chithunzi 13B chonde dziwani kuti Bend (Herzog Curve) pofika kumapeto kwa msomali wa intradellallary singaikidwe kudzera mu malaya amkati. Chifukwa chake, kusilira kwamkati kwamkati kuyenera kuchotsedwa pamsonkhano wa ogwirira asanayikidwe msomali (B; onani Gawo 'ERRORS, zoopsa ndi zoopsa '). Onani malo omaliza a intravedillallary msomali wapansi-posterior ndi njira zambiri. Chotsani ndodo yokonza. Ngati msomali uyenera kusinthidwa, siyani ndodo yotsegulirayo ndikuyika msomali watsopano mu ndodo. 5 ma amm zojambula 5 zogwirizira zimawonetsa kuya kwa kuya kwa cholowera mu proximal tibia (mkuyu. 14). (Chithunzi 14)

⑧ Kutseka kwakanthawi komanso kolowera

Chithunzi cha 14A chofananira komanso chosakanikirana chotseka chimadalira mawonekedwe enieni. Kutsekera kofikira kumatha kuchitika ndi mkono wowoneka bwino. Kutsetserera kwa kusokonekera kumachitika mwaulere kapena kudzera mu ntchito ya radioopapque bud. Mwakusankha, kapu yomaliza itha kugwiritsidwa ntchito, yomwe imalepheretsa kuti imamera kumapeto kwa mkati mwa msomali wa intravedillal ndikuthandizira kuti pambuyo pake. Makamaka misomali yolowera kwambiri ndiyosavuta kuchotsa pomwe malo okwanira kutalika amagwiritsidwa ntchito. Kutalika kwa kapu yomaliza kumayesedwa ndikuyika chizindikiro pa chogwirizira kapena ndikuyika waya wowongolera kudzera mkono wa mawonekedwe.

Chithunzi 14b nsonga ya bwaloli ikuwonetsa malo ofikira a nonsemillallarylary. Cholinga cholumikizira dzanja la msomali chimafunikira kuchotsedwa kuti akhazikitse kapu yomaliza. Chipewa chomaliza chimadutsa mbiya ya kuyika. Chogwirizira chogwirizira. Izi zikugwirizana ndi kapu yomaliza ndi msomali wa intravedillallary ndipo imalepheretsa kuti isatayike. Kuyika chiwongolero kudzera mu khola la mbiya kulowa kumapeto kwa msomali kwa msomali kumathandizanso kuwongolera chipewa cholondola pa msomali wa intramillallarylary. Pamapeto pa njirayi, yankho losabala mchere liyenera kudulidwa kuti lisambe zinyalala zilizonse.

04. Kuchenjeza

Kusamala chifukwa cha opaleshoni

- Pankhani yofatsa nyamakazi, kuyenda koletsedwa kumatha kupewa kulumikizana. Kukhazikika kwa gawo lolowera kwa gulu la Media kapena lofananira kuchokera kumbali ya medive amathandizira kuyiyika pa pini.

- Bondo la ipsilateral la ma prostate sikuti contrakitala yolimbana ndi poyiping. Onani, komabe, kuti sizingatheke kupeza malo omwe amayamba poyambira pompopompo.

- Mu fractures okhala ndi zowonjezera, zomangira zowonjezera zitha kuyikidwa kuti zizigwiritsa ntchito gawo la articular fractor. Ndikulimbikitsidwa kuti zomata izi zigawiridwa zisanachitike misomali kuti mupewe kusamutsidwa kwachiwiri kwa matenda aluso.

Proximal tibia

Mafuta a proximal ndi matenda ovuta kwambiri a tibial ovutikira misomali ndipo amafunikira mfundo zolondola (monga tafotokozera pamwambapa). Izi zimachepetsedwa musanathe kuthana ndi mphamvu zilizonse zoletsedwa ndikuwonjezera kupambana. Nthawi zina, kuyika mawonekedwe omwe akhudzidwa ndi malo owonjezera ndikupeza malo olowera ndikuyika msomali ndi ngalande zomwe zingachitike mu cantonal mu coronal ndi nkhwangwa imabweretsa misala yoyenera.

Komabe, nthawi zambiri, kutsitsa kwina kumafunikira kuti apeze ndikusungabe zokhumudwitsa izi. Ngati mzere wowuluka ndi wosavuta komanso wosavuta, wosavuta kuyambiranso ma clastor kapena kuphatikizika kwa ma claption, omwe adayikidwapo, angagwiritsidwe ntchito, angagwiritsidwe ntchito, angagwiritsidwe ntchito kuti abwezeretse ndikusunganso. Ngati madezi sakhala osakwanira kapena ndege ya kuthyola siyikusinthana, mungu kapena zomangira zoletsa kapena zotchinga zitha kuthandiza kupewa kusamuka komanso kusokonekera (Chithunzi 15). Zomangira izi zimayikidwa kumbuyo kwa mitayilo yofunikira pazinthu zofananira ndi malo omwe akufuna kuti pakhale mawonekedwe oyendayenda. Kuyika koyenera kwa zomata izi kuti zikhale zovuta.

Mkuyu. 15 Zojambula zotsekemera zomwe zimayikidwa kunja kwa njira yofunikira kutsogolo ndi kumbuyo kwa malingaliro ofunikira (b) kutsutsana ndi mphamvu yoletsedwa

Njira ina yothandiza kwambiri ndiyosanthula kwakanthawi kokhala mu harcratur mu anthomu (mkuyu. 16). Nthawi zambiri ndimapulogalamu ang'onoang'ono ang'ono kapena atatu kapena atatu obowola amagwira vuto lomwe limachepera mu mizu caltal ndi misomali. Mbaleyo idzalamulira zonse. Pulogalamuyi iyenera kusiyidwa malinga ngati palibe kusiyana kokhazikika kuti musachepetse kuchepa komwe kumachitika kawirikawiri pambuyo pochotsa magetsi. Mbale iyi yokhala ndi chinsalu chimodzi cha Crical sichimakhazikika ndipo sichikhudza kukhazikika kwa msomali. Njira yobwezeretsanso yobwezeretsanso itha kugwiritsidwa ntchito kwa zotseguka komanso zotsekedwa.

Chithunzi 16 Mbale yaying'ono yokhotakhota yokhala ndi chiwonetsero chimodzi ndi chimodzi chitha kupezeka ndikusungidwa mu mtundu wakuto. Nthawi zambiri, mbaleyo idzasiyidwa m'malo mwa miyala. Kuwonongeka koyamba kwa valgus kwa matenda obwera. b Mphete yaying'ono yopanda chiwonetsero ndi chiwonetsero chimodzi chatha. C Mbale sachotsedwa pambuyo pa misala chifukwa imapereka bata lina

Kulakwika, zoopsa ndi zovuta

- Kusanja kwa stone yoteteza kumatha kuwononga cartilage ndi ma bondo a bondo (Chithunzi 17). Kuteteza kumayikonso kumayenera kuperekedwanso.

- Kutalika pang'ono kwa malaya otetezera kungakulitsenso kuchotsa mutu. Fluoroscopy amathandizira kuzindikira vutoli. Kusintha kwa chiletso choteteza chidzathetsa vuto (mkuyu. 18)

- Malo osanja a Nail: Zowoneka bwino zimatha kukhazikika mu staval malaya a proximal bend (Herzog Curve). Kwa kulowa kwa misomali yomaliza, chubu chachitsulo chikuyenera kuchotsedwa, kusiya pulasitiki yofewa yokha. Pamene msomali ukakhazikika, umafunika kuchotsedwa kwathunthu ndipo kukhazikika kumabwezeretsanso khola lachitsulo kudzera mu canning cannula yokha.

Chithunzi 17 chodzitchinjiriza osayatsidwa popanda fluoroscopic chowonekera chimatha kuyambitsa kuvulala kwa bondo

Chithunzi 18 Kuthamanga kapena mwangozi mwa njira yoteteza kungasokoneze kuchotsedwa kwa Reamer, monga momwe dzina la Reamer ingarere kupanikizana. b fluoroscopic kuyerekezera mwachisawawa kumalola kuchotsedwa kwa mutu wotchuka. C Wobwezera mutu amatha kuchotsedwa ngati mutu wobwereketsa suli m'malo mwake. D Wobwezera mutu amatha kuchotsedwa ngati mutu wobwereketsa suli m'malo mwake.

Maumboni

Hessmann Mh, Buhl m, Finkery a, mosheiry r, huuth m. supratheter mitaing of TiBA. Operaop Orthop zopweteka. 2020 Oct; 32 (5): 440-454.