桡骨远端骨折 资料
您的感受
受伤后，您可能会立即感到手腕和前臂出现剧烈疼痛。这种疼痛通常会持续一段时间。当您尝试活动手或手腕时，疼痛可能会加剧。简单的日常任务可能会变得困难。您可能难以将手伸到背后扣上胸罩。塞衬衫下摆也可能引起疼痛。起初，即使是提起轻物也可能感觉不可能。
肿胀和瘀伤很常见。您的手腕可能看起来肿胀或变色。疼痛可能在夜间加剧，导致难以入睡。您可能会发现侧卧在患侧时感到不适。在早期几天，醒来时手腕僵硬且疼痛是典型症状。这种不适通常通过休息和抬高患肢会得到改善。
手指出现麻木或刺痛感是可能发生的。这是由于肿胀或骨折本身引起的神经刺激。正中神经和尺神经同时受累的情况极为罕见。如果您感到持续性麻木，请告知您的外科医生。早期诊断任何神经或韧带问题有助于预防长期问题。如果不治疗，这些软组织损伤的延迟治疗可能导致10年内出现关节炎。
有些人尝试活动手腕时会感到研磨感。这是因为断裂的骨端相互摩擦。您的外科医生会检查是否伴有其他损伤，例如手腕腕骨韧带损伤。这些软组织并发症可能比骨损伤本身更具问题性。早期准确诊断可为您的康复提供最佳结果。
疼痛管理是您护理的关键部分。您的外科医生将指导您如何管理这种不适。在治疗期间，预防并发症应是首要关注点。早期诊断和治疗对于避免长期后果非常重要。您可能需要保持手腕静止，以便骨骼愈合。这种休息有助于减轻疼痛并防止进一步损伤。
实际发生了什么
当您前臂骨末端骨折时，允许手腕旋转和弯曲的光滑表面可能会变得不平整。可以将这个表面想象成汽车发动机中的垫片。如果垫片出现裂纹或对位不良，关节就无法密封或平滑运动。这会导致您在尝试旋转手部时出现疼痛和僵硬。
骨折通常发生在关节附近的骨骼海绵质部分。该区域在压力下可能会压碎或塌陷。您的外科医生会通过X光片查看骨骼移位程度。目标是将骨块恢复到其原始形态。这被称为恢复解剖对位。正确获得对位是实现良好预后的关键。如果骨骼在错误的位置愈合，您的手腕功能可能无法达到应有的水平。
有时，骨折涉及一块小骨片嵌入关节内。这被称为“冲压碎片”（die punch fragment）。该骨片的大小并不决定您是否需要手术或从手腕的哪一侧进行手术。我们依据其他指征来决定最佳治疗方案。您可能还伴有尺骨（小指侧）的轻微骨折。这种伴随性骨折不会影响您主要腕部骨折的愈合过程。在大多数情况下，我们无需对其进行单独治疗。
神经损伤是一个严重的问题，但联合神经麻痹极为罕见。这意味着手腕的两条主要神经同时受损的情况非常少见。您的外科医生优先考虑预防并发症。早期诊断和治疗有助于避免长期问题。我们使用现代技术，如锁定钢板或带针的外固定架，来固定骨骼。这些方法在骨骼愈合期间提供稳定性。骨骼不愈合的风险极小。这使您能够更早开始手部活动，并更快地恢复功能。
我们能做什么
基兰·希尔帕拉（Kieran Hirpara）医生作为麦特私人医院（Mater Private Hospital Rockhampton）的上肢外科医生，其在诊所中的诊疗方式为您指明了清晰的康复路径。患者通过全科医生或物理治疗师转诊至我们诊所。诊所评估（包括病史采集、体格检查以及必要的影像学检查）用于确立诊断。对于结构性或急性问题，可能会立即建议手术。对于退行性或长期存在的问题，我们通常先尝试非手术治疗。
您可以从自我管理和物理治疗开始。休息手腕并使用冰敷以减轻肿胀。您的物理治疗师将指导您进行温和的活动，以保持关节的灵活性。这种方法旨在通过非侵入性手段恢复正常的活动范围和力量。我们通常会给予保守治疗一段固定的时间以观察疗效，然后再考虑其他选项。早期诊断和治疗对于避免桡骨远端骨折并发症的长期后果至关重要。
如果疼痛持续存在，我们将讨论药物治疗方案。这可能包括使用止痛药或抗炎药来控制不适。在某些情况下，我们会考虑注射治疗。皮质类固醇注射可在有限时间内减轻炎症和疼痛。透明质酸注射可能有助于润滑关节，但其长期疗效的证据各不相同。富血小板血浆（PRP）注射利用您自身的血液成分来支持愈合，但不同患者的疗效可能存在差异。我们根据您具体的症状以及身体对治疗的反应来选择这些方案。
当保守治疗未能带来足够的改善，或者骨骼明显移位时，我们会考虑手术。我们的目标是恢复并维持解剖对位，以确保功能正常。对于移位的骨折，我们使用外固定架结合经皮克氏针的技术。该方法能可靠地获得良好结果，且并发症率低。对于关节外骨折，我们也使用掌侧锁定钢板，并指出部分患者可能会出现一定程度的桡骨高度丢失。伴随的尺骨茎突骨折不影响桡骨远端骨折的预后，因此我们不会因此改变主要治疗方案。我们旨在通过早期识别和管理任何伴随损伤（如软组织并发症或腕骨内在韧带损伤）来实现最佳预后。如果这些问题未得到治疗，延迟诊断可能导致10年内发生关节炎。我们将这些方案作为共同决策提出，确保您充分了解每种路径的风险和益处。
预期情况
您目前最关心的问题可能是疼痛和稳定性。您的外科医生的主要目标是从一开始就预防并发症。早期诊断和治疗对于避免长期后果非常重要。在管理得当的情况下，大多数人会进入稳定的康复阶段。骨不连（骨头未能愈合）的风险极小。
您可能会注意到手腕形状发生一些变化。在接受掌侧锁定钢板固定治疗关节外桡骨远端骨折的患者中，通常会观察到一定程度的桡骨高度丢失。这对许多人来说是愈合过程中的正常现象。伴随的尺骨茎突骨折不会影响桡骨远端骨折的预后。如果这个小骨块也发生了骨折，您无需担心。
软组织问题有时可能比骨损伤本身更令人困扰。这些问题包括肌腱损伤、神经功能障碍或皮肤问题。与桡骨远端骨折相关的正中神经和尺神经联合麻痹极为罕见。如果您出现手腕僵硬，早期准确诊断腕骨内在韧带损伤可获得最佳预后。若未治疗，腕骨内在韧带损伤的延迟诊断将在 10 年内导致关节炎。
康复感受因骨折类型而异。对于移位骨折，结合经皮克氏针的外固定可产生可靠的良好结果。该方法再手术率低，并发症率低。对于桡骨远端骨折，掌侧钢板固定获得的影像学结果优于克氏针固定。然而，在 32 个月随访时，掌侧钢板固定优于克氏针固定的影像学结果并未与更好的功能预后相关。
若不予处理，症状可能会持续或导致关节磨损。前臂骨折脱位治疗的最佳预后取决于早期识别和管理。恢复并维持解剖对位是前臂骨折脱位获得最佳预后的关键原则。骨移植替代物主要用于在桡骨远端骨折中提供结构稳定性。它们被用于或许能在桡骨远端骨折中实现早期功能恢复。
在适当护理下，您的总体预后通常良好。您可以预期在数周至数月内恢复功能。请密切参加随访预约。这使您的外科医生能够早期发现任何软组织问题。您在愈合期间的耐心是取得良好结果的关键。
何时就医
若疼痛持续且休息后无改善，请咨询全科医生。若发现手腕无力或不稳，请要求专科医生评估。若手部出现锁定或无力感，请立即就医。若症状影响睡眠或工作，请联系医生。疼痛或肿胀突然加重需及时诊治。早期诊断有助于避免长期后果。软组织并发症可能比骨损伤本身更为棘手。及时管理神经功能障碍或肌腱损伤可获得更好的预后。切勿忽视血管受损或皮肤问题的迹象。早期识别相关损伤（如腕骨韧带撕裂）可预防未来发生关节炎。
Evidence & references
This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.
Overview
- Prevention of complications associated with distal radius fractures should be the treating surgeon's primary concern [1].
- Early diagnosis and treatment are important to avoid long-term consequences of distal radius fracture complications [1].
- Combined median and ulnar nerve palsy related to distal fractures of the radius is exceedingly rare [2].
- Combined median and ulnar nerve palsy complicating distal radius fractures require a standardised management strategy [2].
- Optimal outcomes in the treatment of forearm fracture–dislocations depend on early recognition and management [4].
- Restoration and maintenance of anatomic alignment are key principles for optimal outcomes in forearm fracture–dislocations [4].
- Novel locking plate designs have resulted in a rethinking of the contemporary approach to distal radius fracture fixation [6].
- A certain degree of radial height loss is noted in patients undergoing fracture fixation with volar locking plate for extra-articular distal radius fractures [7].
- An associated ulnar styloid fracture does not affect the outcomes of a distal radial fracture [8].
- Clinicians should be cautious in electing operative treatment for patients with an ulnar styloid fracture [8].
- Bone graft substitutes are primarily used to provide structural stability in distal radius fractures [9].
- Bone graft substitutes may facilitate early return to function in distal radius fractures [9].
- The risk of nonunion is minimal in distal radius fractures [9].
- External fixation supplemented with percutaneous pins is an excellent option for treating displaced fractures of the distal radius [10].
- External fixation supplemented with percutaneous pins yields reliably good results for displaced distal radius fractures [10].
- External fixation supplemented with percutaneous pins has a low reoperation rate for displaced distal radius fractures [10].
- External fixation supplemented with percutaneous pins has a low complication rate for displaced distal radius fractures [10].
- Die punch fragment size is not an indicator of the need for or use of a dorsal approach in distal radius fracture fixation [17].
Anatomy & Pathophysiology
- Prevention of complications associated with distal radius fractures should be the treating surgeon's primary concern, with early diagnosis and treatment being important to avoid long-term consequences [1].
- Combined median and ulnar nerve palsy related to distal fractures of the radius are exceedingly rare but require a standardized management strategy [2].
- Optimal outcomes in the treatment of forearm fracture–dislocations depend on early recognition and management, with restoration and maintenance of anatomic alignment being the key principles [4].
- An associated ulnar styloid fracture does not affect the outcomes of a distal radial fracture and clinicians should be cautious in electing operative treatment for patients with an ulnar styloid fracture [8].
- Bone graft substitutes are primarily used to provide structural stability and perhaps early return to function in distal radius fractures, where the risk of nonunion is minimal [9].
- Metaphyseal collapse ratio, a novel radiographic parameter, was found to provide a reliable measure of metaphyseal comminution, and to be significantly correlated with other radiographic parameters that predict distal radius fracture instability [11].
- There may be radiographic factors other than measures of deformity that some surgeons use to determine recommendations for surgery [12].
- Early accurate diagnosis of intrinsic carpal ligament injuries provides for best outcomes, while delayed diagnosis leads to arthritis within 10 years if not treated [16].
- DP fragment size is not an indicator of the need for or use of a dorsal approach in distal radius fracture fixation [17].
- Pronation effectively increases the proximal 'safe zone' of the posterior interosseous nerve, suggesting the forearm should be placed in pronation to minimize the risk of iatrogenic injury [18].
- CT scan should be requested only by experienced hand surgeons in order to help guide treatment, as it does not significantly improve inter- and intra-observer agreement for all classification systems [20].
Classification
- CT scans do not significantly improve inter- and intra-observer agreement for the AO, Fernandez, and Universal classification systems for distal radius fractures [20].
- The metaphyseal collapse ratio (MCR) is a novel radiographic parameter that provides a reliable measure of metaphyseal comminution [11].
- The metaphyseal collapse ratio (MCR) is significantly correlated with other radiographic parameters that predict distal radius fracture instability [11].
Clinical Presentation
- Bone graft substitutes are primarily used to provide structural stability and perhaps early return to function in distal radius fractures [9].
- Metaphyseal collapse ratio is a novel radiographic parameter that provides a reliable measure of metaphyseal comminution [11].
- Metaphyseal collapse ratio is significantly correlated with other radiographic parameters that predict distal radius fracture instability [11].
- There may be radiographic factors other than measures of deformity that some surgeons use to determine recommendations for surgery in distal radius fractures [12].
- Soft tissue complications encountered during the management of distal radius fractures include tendon injury, nerve dysfunction, vascular compromise, skin problems, compartment syndrome, and complex regional pain syndrome [15].
- Complications associated with soft tissues may be more problematic than the bone injury itself in distal radius fractures [15].
- Early accurate diagnosis of intrinsic carpal ligament injuries provides for best outcomes [16].
- Delayed diagnosis of intrinsic carpal ligament injuries leads to arthritis within 10 years if not treated [16].
- Pronation effectively increases the proximal 'safe zone' of the posterior interosseous nerve [18].
- The forearm should be placed in pronation to minimize the risk of iatrogenic injury to the posterior interosseous nerve [18].
- Monteggia fractures can be easily overlooked if radiographs of the elbow are not taken [19].
- Pre-existing congenital radial head dislocations can lead to inappropriate surgical intervention if not distinguished from Monteggia fractures [19].
- Early recognition and treatment of Essex-Lopresti injury is associated with improved outcomes [21].
Investigations
- Early diagnosis and treatment of complications associated with distal radius fractures are important to avoid long-term consequences [1].
- Combined median and ulnar nerve palsy related to distal radius fractures is exceedingly rare [2].
- Restoration and maintenance of anatomic alignment are key principles in the treatment of forearm fracture–dislocations [4].
- Pre-existing congenital radial head dislocations can lead to inappropriate surgical intervention if misdiagnosed as Monteggia fractures [19].
Treatment
- Bone graft substitutes are used to perhaps provide early return to function in distal radius fractures [9].
- External fixation supplemented with percutaneous pins for displaced distal radius fractures yields reliably good results [10].
- External fixation supplemented with percutaneous pins for displaced distal radius fractures has a low reoperation rate [10].
- External fixation supplemented with percutaneous pins for displaced distal radius fractures has a low complication rate [10].
- Superior radiological results were attained with volar plating compared to k-wiring for distal radius fractures [13].
- Superior radiological results with volar plating did not correlate with a better functional outcome compared to k-wiring at 32 months follow up [13].
Complications
- Early diagnosis and treatment of complications are important to avoid long-term consequences [1].
- Bone graft substitutes may provide early return to function in distal radius fractures [9].
- The risk of nonunion in distal radius fractures is minimal [9].
Recovery
- Combined median and ulnar nerve palsy complicating distal radius fractures requires a standardised management strategy [2].
- Volar plating attains superior radiological results compared to k-wiring for distal radius fractures [13].
- Superior radiological results with volar plating do not correlate with better functional outcomes compared to k-wiring at 32 months follow up [13].
Key Evidence
- [Paper] Prevention of complications associated with distal radius fractures should be the treating surgeon's primary concern, with early diagnosis and treatment being important to avoid long-term consequences. [1] (10.1016/j.hcl.2014.12.002)
- [Paper] Combined median and ulnar nerve palsy related to distal fractures of the radius are exceedingly rare but require a standardised management strategy. [2] (10.1016/j.otsr.2018.04.026)
- [L5] Optimal outcomes in the treatment of forearm fracture–dislocations depend on early recognition and management, with restoration and maintenance of anatomic alignment being the key principles. [4] (10.1016/j.hcl.2015.01.010)
- [Paper] The management of distal radius fractures is in the midst of a renaissance with novel locking plate designs resulting in a rethinking of the contemporary approach to fracture fixation. [6] (10.1016/j.hcl.2005.04.001)
- [Paper] A certain degree of radial height loss is noted in patients undergoing fracture fixation with volar locking plate for extra-articular distal radius fractures. [7] (10.1016/j.otsr.2021.102842)
- [L1] Based on this meta-analysis, an associated ulnar styloid fracture does not affect the outcomes of a distal radial fracture and clinicians should be cautious in electing operative treatment for patients with an ulnar styloid fracture. [8] (10.1016/j.injury.2017.08.061)
- [L4] Bone graft substitutes are primarily used to provide structural stability and perhaps early return to function in distal radius fractures, where the risk of nonunion is minimal. [9] (10.1016/j.hcl.2012.02.004)
- [L1] External fixation supplemented with percutaneous pins is an excellent option for treating displaced fractures of the distal radius, with reliably good results, a low reoperation rate, and a low complication rate. [10] (10.1016/j.hcl.2009.08.008)
- [Paper] Metaphyseal collapse ratio, a novel radiographic parameter, was found to provide a reliable measure of metaphyseal comminution, and to be significantly correlated with other radiographic parameters that predict distal radius fracture instability. [11] (10.1016/j.otsr.2013.05.002)
- [Paper] There may be radiographic factors other than measures of deformity that some surgeons use to determine recommendations for surgery. [12] (10.1007/s12593-014-0164-0)
- [L3] Although superior radiological results were attained with volar plating, these results did not correlate with a better functional outcome compared to k-wiring at 32 months follow up. [13] (10.1016/j.injury.2015.08.040)
- [L5] This review focuses on soft tissue complications encountered during the management of distal radius fractures, including tendon injury, nerve dysfunction, vascular compromise, skin problems, compartment syndrome, and complex regional pain syndrome, noting that complications associated with soft tissues may be more problematic than the bone injury itself. [15] (10.1016/j.hcl.2009.11.002)
- [L5] Early accurate diagnosis of intrinsic carpal ligament injuries provides for best outcomes, while delayed diagnosis leads to arthritis within 10 years if not treated. [16] (10.1016/j.hcl.2015.01.003)
- [Paper] DP fragment size is not an indicator of the need for or use of a dorsal approach in DRF fixation. [17] (10.1055/s-0040-1712328)
- [Paper] Pronation effectively increases the proximal 'safe zone' of the nerve, suggesting the forearm should be placed in pronation to minimize the risk of iatrogenic injury. [18] (10.1016/j.injury.2015.01.028)
- [L4] Monteggia fractures can be easily overlooked if radiographs of the elbow are not taken, and pre-existing congenital radial head dislocations can lead to inappropriate surgical intervention. [19] (10.1016/j.injury.2005.08.028)
- [Paper] CT scan should be requested only by experienced hand surgeons in order to help guide treatment, as it does not significantly improve inter- and intra-observer agreement for all classification systems. [20] (10.1016/j.injury.2014.06.017)
- [L5] Early recognition and treatment is associated with improved outcomes. [21] (10.1016/j.hcl.2020.07.012)
References
[1] Management of Complications of Distal Radius Fractures. Hand Clinics. 2015. DOI: 10.1016/j.hcl.2014.12.002
[2] Combined median and ulnar nerve palsy complicating distal radius fractures. Orthopaedics & Traumatology: Surgery & Research. 2018. DOI: 10.1016/j.otsr.2018.04.026
[4] Management of Complications of Forearm Fractures. Hand Clinics. 2015. DOI: 10.1016/j.hcl.2015.01.010
[6] Distal Radius Fractures. Hand Clinics. 2005. DOI: 10.1016/j.hcl.2005.04.001
[7] Loss of radial height in extra-articular distal radial fracture following volar locking plate fixation. Orthopaedics & Traumatology: Surgery & Research. 2021. DOI: 10.1016/j.otsr.2021.102842
[8] Does concomitant ulnar styloid fracture and distal radius fracture portend poorer outcomes? A meta-analysis of comparative studies. Injury. 2017. DOI: 10.1016/j.injury.2017.08.061
[9] The Use of Bone Grafts and Substitutes in the Treatment of Distal Radius Fractures. Hand Clinics. 2012. DOI: 10.1016/j.hcl.2012.02.004
[10] External Fixation of Distal Radius Fractures. Hand Clinics. 2010. DOI: 10.1016/j.hcl.2009.08.008
[11] Distal radius fracture metaphyseal comminution: A new radiographic parameter for quantifying, the metaphyseal collapse ratio (MCR). Orthopaedics & Traumatology: Surgery & Research. 2013. DOI: 10.1016/j.otsr.2013.05.002
[12] Radiographs Versus Radiographic Measurements in Distal Radius Fractures. Journal of Hand and Microsurgery. 2015. DOI: 10.1007/s12593-014-0164-0
[13] Volar plate versus k-wire fixation of distal radius fractures. Injury. 2016. DOI: 10.1016/j.injury.2015.08.040
[15] Soft Tissue Complications of Distal Radius Fractures. Hand Clinics. 2010. DOI: 10.1016/j.hcl.2009.11.002
[16] Management of Complications of Ligament Injuries of the Wrist. Hand Clinics. 2015. DOI: 10.1016/j.hcl.2015.01.003
[17] The Die Punch Fragment: Analysis of Fragment Geometry and Need for Fixation. Journal of Hand and Microsurgery. 2022. DOI: 10.1055/s-0040-1712328
[18] The course of the posterior interosseous nerve in relation to the proximal radius: Is there a reliable landmark?. Injury. 2015. DOI: 10.1016/j.injury.2015.01.028
[19] When is a Monteggia fracture not a Monteggia fracture?. Injury Extra. 2007. DOI: 10.1016/j.injury.2005.08.028
[20] Does the CT improve inter- and intra-observer agreement for the AO, Fernandez and Universal classification systems for distal radius fractures?. Injury. 2014. DOI: 10.1016/j.injury.2014.06.017
[21] The Essex-Lopresti Injury:. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.07.012
