胫骨髓内钉断裂远端部分如何取出

胫骨髓内钉断裂远端部分如何取出 胫骨髓内钉断裂远端部分如何取出:手术技巧 2012-02-05 11:48 来源:丁香园 作者:hotstone 胫骨髓内钉断裂后如何取出远端部分，对创伤骨科医生而言是具有挑战性的。以往报道的方法也不少，可应用不同的工具，如骨钩、T型铰刀、多枚球头导针等作为拔出器取出空心髓内钉断裂后的远端部分[1-4]。然而，如果断裂的远端部分很短，且直径较小时，应用这些方法通常都无法凑效。本文介绍一种新的方法来解决这一问题。 手术方法 应用可透X线的手术床，患者取仰卧位，应用常规的方法在C臂影像监视下取出断裂的近端部分，然后取出远端部分的锁钉。在胫骨前唇和髓内钉远端之间做一个1cm的穿刺切口，显露胫骨前侧皮质。C臂辅助下应用徒手技术从前侧皮质穿入一枚3.6mm直径的导针(图1A)，同样徒手用斯氏针将进针点入口处的皮质稍稍纵向扩大一些，然后替换斯氏针，置入一把4-6mm直径的冲击器(图1B)，顶住髓内钉尖端后，向近端敲击，尽量将断裂的髓内钉回敲少许。接下来，用3mm直径的球头导针穿入7mm直径的AO垫片，插入髓内钉断端的内腔(图2)。导针沿髓腔一直向上，从胫骨髓内钉先前的入口处穿出(图3)。接下来便可通过近端开放的髓腔拔出断裂的髓内钉(图4)。 Is team-oriented and team building. Persisting in democratic centralism, improve the level of team science decision, a democratic decision. Strengthening the concept of collective leadership, by collective discussions and decisions on major issues. 5 years, between members of the team did Frank, equal treatment, mutual trust, mutual support and form a innovation-oriented, democratic solidarity and diligent people, honest type of four good teams. Second, focus on the transformation of work style. Requires team members to actively think, active officers to organize work, active inspection work, initiative, by the Office and of the primary station and village (community), and make sure regardless of Division of labor and mutual support, mutual Help and complement each other, understand each other, improve leadership skills of managing. Third party organizations are weak and lax, strengthening regulation (community) party organizations and cadres, improve service levels, and enhance team effectiveness. The work style of the party members and cadres in the whole town has been further changes. 2. the cadres, and improve the overall quality of party members and cadres. First, grasp the cadres team construction. Cadres of the new and improved the regulation, the town village appraisal methods, training of party members and other 8 work, effectively promote the work, put an end to the previous shuffle, prevarication is not responsible for the phenomenon. Second, strengthening the construction of grassroots party organizations and party members. Catch the party branch Secretary of team-building, improving overall quality. Healthy village (community) cadre appointment system. Perfect village Is team-oriented and team building. Persisting in democratic centralism, improve the level of team science decision, a democratic decision. Strengthening the concept of collective leadership, by collective discussions and decisions on major issues. 5 years, between members of the team did Frank, equal treatment, mutual trust, mutual support and form a innovation-oriented, democratic solidarity and diligent people, honest type of four good teams. Second, focus on the transformation of work style. Requires team members to actively think, active officers to organize work, active inspection work, initiative, by the Office and of the primary station and village (community), and make sure regardless of Division of labor and mutual support, mutual Help and complement each other, understand each other, improve leadership skills of managing. Third party organizations are weak and lax, strengthening regulation (community) party organizations and cadres, improve service levels, and enhance team effectiveness. The work style of the party members and cadres in the whole town has been further changes. 2. the cadres, and improve the overall quality of party members and cadres. First, grasp the cadres team construction. Cadres of the new and improved the regulation, the town village appraisal methods, training of party members and other 8 work, effectively promote the work, put an end to the previous shuffle, prevarication is not responsible for the phenomenon. Second, strengthening the construction of grassroots party organizations and party members. Catch the party branch Secretary of team-building, improving overall quality. Healthy village (community) cadre appointment system. Perfect village 图1 A胫骨远端前侧皮质经皮开口，徒手置入3.6mm斯氏针;B 将斯氏针替换为冲击器。 图2 用冲击器顶住髓内钉尖端回敲，直至有足够的空间可以置入导针。 Is team-oriented and team building. Persisting in democratic centralism, improve the level of team science decision, a democratic decision. Strengthening the concept of collective leadership, by collective discussions and decisions on major issues. 5 years, between members of the team did Frank, equal treatment, mutual trust, mutual support and form a innovation-oriented, democratic solidarity and diligent people, honest type of four good teams. Second, focus on the transformation of work style. Requires team members to actively think, active officers to organize work, active inspection work, initiative, by the Office and of the primary station and village (community), and make sure regardless of Division of labor and mutual support, mutual Help and complement each other, understand each other, improve leadership skills of managing. Third party organizations are weak and lax, strengthening regulation (community) party organizations and cadres, improve service levels, and enhance team effectiveness. The work style of the party members and cadres in the whole town has been further changes. 2. the cadres, and improve the overall quality of party members and cadres. First, grasp the cadres team construction. Cadres of the new and improved the regulation, the town village appraisal methods, training of party members and other 8 work, effectively promote the work, put an end to the previous shuffle, prevarication is not responsible for the phenomenon. Second, strengthening the construction of grassroots party organizations and party members. Catch the party branch Secretary of team-building, improving overall quality. Healthy village (community) cadre appointment system. Perfect village Is team-oriented and team building. Persisting in democratic centralism, improve the level of team science decision, a democratic decision. Strengthening the concept of collective leadership, by collective discussions and decisions on major issues. 5 years, between members of the team did Frank, equal treatment, mutual trust, mutual support and form a innovation-oriented, democratic solidarity and diligent people, honest type of four good teams. Second, focus on the transformation of work style. Requires team members to actively think, active officers to organize work, active inspection work, initiative, by the Office and of the primary station and village (community), and make sure regardless of Division of labor and mutual support, mutual Help and complement each other, understand each other, improve leadership skills of managing. Third party organizations are weak and lax, strengthening regulation (community) party organizations and cadres, improve service levels, and enhance team effectiveness. The work style of the party members and cadres in the whole town has been further changes. 2. the cadres, and improve the overall quality of party members and cadres. First, grasp the cadres team construction. Cadres of the new and improved the regulation, the town village appraisal methods, training of party members and other 8 work, effectively promote the work, put an end to the previous shuffle, prevarication is not responsible for the phenomenon. Second, strengthening the construction of grassroots party organizations and party members. Catch the party branch Secretary of team-building, improving overall quality. Healthy village (community) cadre appointment system. Perfect village 图3 带垫片的导针逆向插入，通过整个髓腔从胫骨髓内钉原进针点穿出。 Is team-oriented and team building. Persisting in democratic centralism, improve the level of team science decision, a democratic decision. Strengthening the concept of collective leadership, by collective discussions and decisions on major issues. 5 years, between members of the team did Frank, equal treatment, mutual trust, mutual support and form a innovation-oriented, democratic solidarity and diligent people, honest type of four good teams. Second, focus on the transformation of work style. Requires team members to actively think, active officers to organize work, active inspection work, initiative, by the Office and of the primary station and village (community), and make sure regardless of Division of labor and mutual support, mutual Help and complement each other, understand each other, improve leadership skills of managing. Third party organizations are weak and lax, strengthening regulation (community) party organizations and cadres, improve service levels, and enhance team effectiveness. The work style of the party members and cadres in the whole town has been further changes. 2. the cadres, and improve the overall quality of party members and cadres. First, grasp the cadres team construction. Cadres of the new and improved the regulation, the town village appraisal methods, training of party members and other 8 work, effectively promote the work, put an end to the previous shuffle, prevarication is not responsible for the phenomenon. Second, strengthening the construction of grassroots party organizations and party members. Catch the party branch Secretary of team-building, improving overall quality. Healthy village (community) cadre appointment system. Perfect village Is team-oriented and team building. Persisting in democratic centralism, improve the level of team science decision, a democratic decision. Strengthening the concept of collective leadership, by collective discussions and decisions on major issues. 5 years, between members of the team did Frank, equal treatment, mutual trust, mutual support and form a innovation-oriented, democratic solidarity and diligent people, honest type of four good teams. Second, focus on the transformation of work style. Requires team members to actively think, active officers to organize work, active inspection work, initiative, by the Office and of the primary station and village (community), and make sure regardless of Division of labor and mutual support, mutual Help and complement each other, understand each other, improve leadership skills of managing. Third party organizations are weak and lax, strengthening regulation (community) party organizations and cadres, improve service levels, and enhance team effectiveness. The work style of the party members and cadres in the whole town has been further changes. 2. the cadres, and improve the overall quality of party members and cadres. First, grasp the cadres team construction. Cadres of the new and improved the regulation, the town village appraisal methods, training of party members and other 8 work, effectively promote the work, put an end to the previous shuffle, prevarication is not responsible for the phenomenon. Second, strengthening the construction of grassroots party organizations and party members. Catch the party branch Secretary of team-building, improving overall quality. Healthy village (community) cadre appointment system. Perfect village 图4 带垫片的导针作为拔出装置，取出断裂的髓内钉。 髓内钉断裂后如何取出远端部分，在以往的研究中报道了多种方法[1-4]。对于断裂的股骨髓内钉，远端部分既可通过近端取出也可从远端取出，而胫骨髓内钉断裂后，一般只能通过胫骨近段髓腔而取出[5]。在这种情况下，可应用多种工具，打拔出断裂的髓内钉，这些工具包括骨钩，T型铰刀、多枚球头导针等。然而，打拔工具与髓内钉断端之间滑脱仍是导致手术方法失败的主要原因。例如，髓内钉内腔直径较小时，无法插入多枚球头导针，因为髓内钉尖端的内腔只能够穿入一枚3mm的导针。对于股骨髓内钉断裂，应用Magu等的经验，我们积累了一些成功的经验，球头导针套上垫片后，从髁间窝开口插入远折端，从髓腔取出断裂的髓内钉[6]。因此，我们改良了这一技术用于取出断裂的胫骨髓内钉。由于踝关节的解剖关系，必须将断端部分向上回敲以后才有足够的空间将带垫片的导针穿入髓内钉的内腔。皮质通道的建立，可在影像监视下，应用徒手技术，在胫骨前唇和髓内钉尖端之间从前侧皮质开口。并可轻易地纵向扩大皮质入口，以便置入4-6mm的冲击器。在应用屈曲的小冲击器之前，可先用斯氏针处理髓内钉的尖端。因此，对于髓内钉尖端置入到软骨下骨的情况，也可应用这一方法。在这种特定的情况下，应用3mm的扩髓导针尤其合适，一方面具有良好的韧性，另一方面这一直径与7mm AO垫片以及髓内钉的内腔均可获得完美的匹配。穿入7mm垫片后，插入导针时，由于垫片与导针之间有足够的间隙，可以在倾斜的位置上轻易地穿入骨隧道。与整个胫骨远端的大小相比，进针时造成的皮质缺口相对较小，在作者的病例中，没有出现任何由于该缺口而导致的不良 Is team-oriented and team building. Persisting in democratic centralism, improve the level of team science decision, a democratic decision. Strengthening the concept of collective leadership, by collective discussions and decisions on major issues. 5 years, between members of the team did Frank, equal treatment, mutual trust, mutual support and form a innovation-oriented, democratic solidarity and diligent people, honest type of four good teams. Second, focus on the transformation of work style. Requires team members to actively think, active officers to organize work, active inspection work, initiative, by the Office and of the primary station and village (community), and make sure regardless of Division of labor and mutual support, mutual Help and complement each other, understand each other, improve leadership skills of managing. Third party organizations are weak and lax, strengthening regulation (community) party organizations and cadres, improve service levels, and enhance team effectiveness. The work style of the party members and cadres in the whole town has been further changes. 2. the cadres, and improve the overall quality of party members and cadres. First, grasp the cadres team construction. Cadres of the new and improved the regulation, the town village appraisal methods, training of party members and other 8 work, effectively promote the work, put an end to the previous shuffle, prevarication is not responsible for the phenomenon. Second, strengthening the construction of grassroots party organizations and party members. Catch the party branch Secretary of team-building, improving overall quality. Healthy village (community) cadre appointment system. Perfect village