桡骨远端骨折

　　Distal radial fractures are very common, accounting for about1/10。多见于老年妇女，青壮年发生均为外伤暴力较大者。此病可分为三类，其病因分别为：

　　1、伸直型骨折(Colles骨折)

　　最常见，多为间接暴力致伤。1814年由A.Colles详加描述。跌倒时腕关节处于背伸及前臂旋前位、手掌着地，暴力集中于桡骨远端松质骨处而引起骨折。骨折远端向背侧及桡侧移位。儿童可为骨骺分离；老年由于骨质疏松，轻微外力即可造成骨折且常为粉碎骨折，骨折端因嵌压而短缩。粉碎骨折可累及关节面或合并尺骨茎突撕脱骨折及下尺桡关节脱位。

　　2、屈曲型骨折(Smith骨折)

　　较少见，由R.W.Smith在1874年首次描述。骨折发生原因与伸直型骨折相反，故又称反Colles骨折。跌倒时手背着地，骨折远端向掌侧及尺侧移位。

　　3、巴尔通骨折(Barton骨折)

　　系指桡骨远端关节面纵斜型骨折，伴有腕关节脱位者。由J.R.Barton1838年首次描述。跌倒时手掌或手背着地，暴力向上传递，通过近排腕骨的撞击引起桡骨关节面骨折，在桡骨下端掌侧或背侧形成一带关节面软骨的骨折块，骨块常向近侧移位，并腕关节脱位或半脱位。

　　Distal radial fractures are very common, accounting for about1/10. More common in elderly women, and young adults occur in those with greater trauma. Fractures occur in the distal end of the radius2～3cm range. Often accompanied by damage to the radiocarpal and ulnar and radial joints. Some complications may occur in this disease:

　　1、Malunion

　　Not accurately reducing and reliably fixing is the main cause of malunion of fractures, the extra-articular criteria for the treatment of distal radial fractures include the restoration of the palmar inclination angle, the ulnar deviation and height of the radius, the universally accepted standard is the separation of the radiocarpal joint less than2 mm, the inclination angle of the dorsal side is less than10degree, the shortening of the radius is less than5 mm, dorsal or volar comminuted fractures, severe dorsal angulation or incomplete reduction may be signs of potential redisplacement and malunion after fixation, wrist dorsal deformity is mainly due to掌屈, ulnar deviation not in place while healing in deformity, while wrist volar deformity is due to excessive flexion during reduction, causing the distal end to move towards the volar side without correction, especially in elderly patients with osteoporosis, excessive force during reduction can produce. The incidence of redisplacement after reduction of distal radial fractures is high, especially in comminuted fractures, it is more likely to occur during fixation and heal in deformity. Obvious deformity will seriously affect wrist joint function.

　　2、Dislocation of the ulnar and radial joints

　　Dislocation of the ulnar and radial joints is most likely to occur in distal radial fractures and is easily overlooked. The stability of the ulnar and radial joints mainly depends on the joint disc and the ulnar and radial volar and dorsal ligaments. When the wrist is extended and falls, the ligaments may rupture, leading to dislocation of the ulnar and radial bones. Early identification and treatment of ulnar and radial joint injuries associated with distal radial fractures are crucial for reducing the incidence of pain and functional impairment. X-ray examination shows that the ulnar and radial joints are greater than3mm, that is, the dislocation of the ulnar and radial joints, accurate reduction and reliable fixation of the distal radial fracture can help to reduce and heal the dislocated ulnar and radial joints.

　　3、Median nerve entrapment

　　The position of reduction and fixation of the distal radial fracture causes wrist flexion, displacement of the fracture and hematoma can increase the pressure inside the carpal tunnel, which may lead to median nerve compression and carpal tunnel syndrome in severe cases. Good reduction and alignment after reduction of the fracture can reduce the incidence of median nerve entrapment, and early detection and early relief of median nerve entrapment can alleviate hand dysfunction.

　　4、Severe traumatic wrist arthritis

　　Maintaining the flatness of the joint surface is an important condition for the recovery of joint function in distal radial fractures, for comminuted fractures, the most important criterion for successful treatment is the reconstruction within the joint, that is, the accuracy of joint surface restoration, the joint surface flatness over2mm is an indication for surgery, we use lever manipulation reduction followed by pin fixation to treat distal radial fractures involving the wrist or comminuted, extremely unstable fractures, with good results.

　　5、Fascial compartment syndrome of the forearm

　　The fixation of the掌屈尺偏加压 can increase the pressure in the anterior forearm fascial compartment, excessive wrist flexion can reduce venous return, further increasing the pressure in the fascial compartment. In severe cases, fascial compartment syndrome may occur. Therefore, observing hand blood supply and pain nature after plaster or splint fixation can reveal the early signs of fascial compartment syndrome, so that timely treatment can be provided to avoid more serious complications.

　　发生桡骨远端骨折的患者，主要有以下的一些临床表现：

　　手腕疼痛肿胀，尤其以掌屈活动受限，骨折移位严重者，可出现餐叉状畸形，即腕部背侧隆起，掌侧突出，尺骨茎突轮廓消失，腕部增宽，手向桡侧移位，尺骨下端突出，桡骨茎突上移达到或超过尺骨茎突水平，桡骨远端有压痛，可触及向桡背移位的骨折端，粉碎骨折可触及骨擦音。

　　本病是由于外伤性因素引起，无特殊的预防措施，对本病的防治，重点在预防并发症的发生，特别是老年，主要有以下几个要点：

　　(1)及时的门诊复查

　　复查时间一般以第1周每2天复查1次，1周后每周复查1次，首先检查绷带松紧及肿胀情况，骨折固定时根据手腕及前臂肿胀情况随时调整夹板绷带和石膏夹的松紧度，4周时摄X线片显示骨折愈合，可解除固定，积极进行功能锻炼。

　　(2)防止肌腱，神经损伤

　　一般克雷氏骨折在固定时，多采用掌屈尺偏位固定，可使腕管内压力增加，有的易压迫正中神经，有的可因骨折端畸形愈合，加上长时间固定，可造成拇长伸肌腱断裂，在复查过程中应与予重视，一旦发现应及时手术探查治疗。

　　(3)早期应控制旋前移位

　　固定时应将患肢保持在旋后15°位或中立位，旋前固定往往使前臂旋后功能受限，应及时纠正，放回到旋后位，否则将影响前臂的旋转功能。

　　(4)早期正确的功能锻炼

　　患者应克服因功能锻炼所致的怕疼怕肿，担心骨折脱位的顾虑，在准确的复位及局部牢固外固定下，及早进行患肢的功能锻炼，先进行被动活动，再进行主动活动，功能锻炼要循序渐进，固定当日即可进行活动手指关节，握拳松拳活动，活动次数逐渐增多，同时做肩肘关节的屈伸运动，骨折愈合后，应及早去除外固定，配合理疗，全面做肩，肘，腕关节各方面活动，尤其加强握拳松拳动作的锻炼，恢复肌力和肌肉协调功能，防止因肌肉萎缩造成的功能障碍。

　　桡骨远端骨折的辅助检查方法主要是X线检查，X线摄片显示典型移位，有以下几个要点：

　　1、桡骨远端骨折块向背侧移位。

　　2、桡骨远端骨折块向桡侧移位。

　　3、桡骨短缩，骨折处背侧骨皮质嵌入或为粉碎骨折。

　　4、骨折处向掌侧成角。

　　5、桡骨远端骨块旋后。

　　此外还显示尺骨头半脱位或全脱位，桡骨远端骨折向桡侧移位说明三角软骨边缘撕裂，常合并有尺骨茎突撕脱骨折，掌倾角与尺偏角减少或呈负角。

　　桡骨远端骨折可分为多种类型，多见于老年妇女，青壮年发生均为外伤暴力较大者。临床以腕部肿胀、压痛明显，手和腕部活动受限为主。患者在饮食上应注意，可以多吃以下食物：

　　1、高能量、高蛋白膳食：有助于恢复元气。但宜在骨折2周后食用。骨折初期还应以清淡饮食为宜。

　　2、维生素D：骨折后若一直在室内休养，晒不到太阳，容易缺乏致维生素D。因此骨折后要多吃富含维生素D的食物(如鱼、肝脏、蛋黄等)，并尽可能多晒些太阳。

　　3、维C：富含维生素c的水果有山楂、鲜枣、猕猴桃、草莓、桂圆、荔枝、柑橘等，蔬菜则有黄花苜蓿(草头)、辣椒、甜椒、油菜薹、花椰菜、抱子甘蓝(汤菜)、苦瓜、豆瓣菜、绿花菜、青苋菜等。

　　4、水：骨折后由于久坐不动，容易引发便秘，此时应多喝些水来保证肠道畅通。

　　骨折后2周，可补充的饮食有骨头汤、田七煲鸡、动物肝脏之类，以补给更多的维生素a、d，钙及蛋白质。骨折5周以上，食谱可再配以老母鸡汤、猪骨汤、羊骨汤、鹿筋汤、炖水鱼等，能饮酒者可选用杜仲骨碎补酒、鸡血藤酒、虎骨木瓜酒等。

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