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一期闭合复位双克氏针弹性加压固定治疗Wehbe-SchneiderⅠB型及ⅡB型骨性锤状指

Treatment of Wehbe-Schneider types Ⅰ B and Ⅱ B bony mallet fingers with one-stage closed reduction and elastic compression fixation with double Kirschner wires

伟峰李 , ^1, ^2, ³ 敬标张 , ¹ 庆安 , ¹ 志远郑 , ¹ and 建中官 ^2, ^3, ^*

伟峰李

敬标张

利辛县人民医院骨一科（安徽亳州 236700）, The First Department of Orthopedics, the People’s Hospital of Lixin County, Bozhou Anhui, 236700, P. R. China

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庆安

利辛县人民医院骨一科（安徽亳州 236700）, The First Department of Orthopedics, the People’s Hospital of Lixin County, Bozhou Anhui, 236700, P. R. China

Find articles by 庆安

志远郑

利辛县人民医院骨一科（安徽亳州 236700）, The First Department of Orthopedics, the People’s Hospital of Lixin County, Bozhou Anhui, 236700, P. R. China

Find articles by 志远郑

建中官

利辛县人民医院骨一科（安徽亳州 236700）, The First Department of Orthopedics, the People’s Hospital of Lixin County, Bozhou Anhui, 236700, P. R. China 蚌埠医学院第一附属医院骨科（安徽蚌埠 233004）, Department of Orthopedics, the First Affiliated Hospital, Bengbu Medical College, Bengbu Anhui, 233004, P. R. China 利辛县人民医院骨一科（安徽亳州 236700）, The First Department of Orthopedics, the People’s Hospital of Lixin County, Bozhou Anhui, 236700, P. R. China 蚌埠医学院第一附属医院骨科（安徽蚌埠 233004）, Department of Orthopedics, the First Affiliated Hospital, Bengbu Medical College, Bengbu Anhui, 233004, P. R. China 组织移植安徽省重点实验室（安徽蚌埠 233030）, Anhui Province Key Laboratory of Tissue Transplantation, Bengbu Anhui, 233030, P. R. China

Corresponding author.

建中官: nc.ude.cmbb@gnohznaijnaug

官建中，Email： nc.ude.cmbb@gnohznaijnaug

结论

对于Wehbe-Schneider ⅠB、ⅡB型骨性锤状指，一期闭合复位双克氏针弹性加压固定可有效纠正畸形，具有操作简便、手术无切口不影响患指外观等优点。

Keywords: 骨性锤状指, 撕脱骨折, 闭合复位, 克氏针, 内固定

Abstract

Objective

To investigate the effectiveness of one-stage closed reduction and elastic compression fixation with double Kirschner wires for Wehbe-Schneider types ⅠB and ⅡB bony mallet fingers.

Methods

Between May 2017 and June 2020, 21 patients with Wehbe-Schneider type ⅠB and ⅡB bony mallet fingers were treated with one-stage closed reduction and elastic compression fixation using double Kirschner wires. There were 15 males and 6 females with an average age of 39.2 years (range, 19-62 years). The causes of injury were sports injury in 9 cases, puncture injury in 7 cases, and sprain in 5 cases. The time from injury to admission was 5-72 hours (mean, 21.0 hours). There were 2 cases of index finger injury, 8 cases of middle finger injury, 9 cases of ring finger injury, and 2 cases of little finger injury. The angle of active dorsiflexion loss of distal interphalangeal joint (DIPJ) was (40.04±4.02)°. According to the Wehbe-Schneider classification standard, there were 10 cases of typeⅠB and 11 cases of type ⅡB. The Kirschner wire was removed at 6 weeks after operation when X-ray film reexamination showed bony union of the avulsion fracture, and the functional exercise of the affected finger was started.

Results

The operation time was 35-55 minutes (mean, 43.9 minutes). The length of hospital stay was 2-5 days (mean, 3.4 days). No postoperative complications occurred. All patients were followed up 6-12 months (mean, 8.8 months). X-ray films reexamination showed that all avulsion fractures achieved bony union after 4-6 weeks (mean, 5.3 weeks). Kirschner wire was removed at 6 weeks after operation. After Kirschner removal, the visual analogue scale (VAS) score of pain during active flexion of the DIPJ was 1-3 (mean, 1.6); the VAS score of pain was 2-5 (mean, 3.1) when the DIPJ was passively flexed to the maximum range of motion. The angle of active dorsiflexion loss of affected finger was (2.14±2.54)°, showing significant difference when compared with preoperative angle ( t =52.186, P <0.001). There was no significant difference in the active flexion angle between the affected finger (79.52±6.31)° and the corresponding healthy finger (81.90±5.36)° ( t =1.319, P =0.195). At 6 months after operation, according to Crawford functional evaluation criteria, the effectiveness was rated as excellent in 11 cases, good in 9, and fair in 1, with an excellent and good rate of 95.24%.

Conclusion

For Wehbe-Schneider typesⅠB and ⅡB bony mallet fingers, one-stage closed reduction and elastic compression fixation with double Kirschner wires can effectively correct the deformity and has the advantages of simple surgery, no incision, and no influence on the appearance of the affected finger.

Keywords: Bony mallet finger, avulsion fracture, closed reduction, Kirschner wire, internal fixation

锤状指是临床较常见的手部损伤 ^{[

1

-

2

]} ，分为肌腱性和骨性两种类型。其中，骨性锤状指更常见 ^{[

3

]} ，为末节指骨基底部撕脱骨折引起末节伸肌装置损伤造成 ^{[

4

-

5

]} 。根据Wehbe-Schneider分型标准 ^{[

6

]} ，骨性锤状指可分为Ⅰ、Ⅱ、Ⅲ型；根据远端指间关节（distal interphalangeal joint，DIPJ）远侧关节面累及程度，上述3型又可进一步分为A、B、C亚型。其中，ⅠB、ⅡB型骨折均累及DIPJ远侧关节面1/3～2/3，但前者DIPJ无脱位、后者呈半脱位。此类型损伤如未治疗或治疗不当，可能导致DIPJ伸直受限、关节僵硬、“天鹅颈”畸形及继发性骨关节炎 ^{[

7

-

8

]} 。

Wehbe-SchneiderⅠB、ⅡB型骨性锤状指可保守治疗或手术治疗，但保守治疗外固定制动不可靠，而且不能恢复原有伸指肌腱长度 ^{[

9

]} ，故临床以手术治疗为主 ^{[

10

-

11

]} 。开放性手术创伤较大且并发症多，同时遗留明显瘢痕，影响DIPJ功能和外观。闭合复位手术则可避免以上并发症。2017年5月—2020年6月，利辛县人民医院骨一科采用一期闭合复位双克氏针弹性加压固定治疗21例Wehbe-Schneider ⅠB、ⅡB型骨性锤状指，获得满意疗效。报告如下。

1. 临床资料

1.1. 一般资料

本组男15例，女6例；年龄19～62岁，平均39.2岁。致伤原因：运动伤9例，戳伤7例，扭伤5例。均为闭合性损伤。受伤至入院时间5～72 h，平均21.0 h。损伤指别：示指2例，中指8例，环指9例，小指2例。入院检查患指DIPJ处呈“锤状”畸形，局部稍肿胀、无破损，DIPJ主动背伸丧失角度为（40.04±4.02）°。患指均行正侧位X线片检查，可见末节指骨背侧基底部撕脱骨折，DIPJ无脱位或半脱位；根据Wehbe-Schneider分型标准：ⅠB型10例，ⅡB型11例。

1.2. 手术方法

采用指根神经阻滞麻醉，患者取仰卧位，常规消毒铺巾、指根上止血带。术者缓慢屈曲患指DIPJ，维持在约90° 位置；紧贴撕脱骨块背侧、从DIPJ关节面中点近背侧缘1～2 mm处进针，由远端沿中节指骨纵轴向近端钻入1枚1.0 mm 克氏针以阻挡骨块，注意克氏针尽可能靠近骨块，并避免克氏针过深而伤及近端关节面。然后，向远端持续牵引DIPJ并缓慢背伸至轻度过伸位（5°～10°），随角度增大，撕脱骨折可以逐渐复位，此时第1枚克氏针与纵轴成角约40°，其持续回弹作用力起到加压固定骨块的作用；再从指尖沿远节指骨纵轴跨DIPJ向近端钻入第2枚1.0 mm克氏针，固定并维持DIPJ于过伸位。C臂X线机透视骨折对位对线情况，确认骨折复位后，将2枚克氏针尾端折弯后保留适当长度在皮肤外，以备后期取出。见图1 。

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图 1

Schematic diagram of closed reduction and Kirschner wire fixation of fractures

骨折闭合复位及克氏针固定操作示意图

a. 钻入第1枚克氏针；b、c. 骨折闭合复位并钻入第2枚克氏针；d. 第1枚克氏针弯曲后加压固定骨块

a. Inserted the 1st Kirschner wire; b, c. Closed reduction of fracture and inserted the 2nd Kirschner wire; d. The 1st Kirschner wire after bending was pressed to fix the fracture fragment

1.3. 术后处理

所有患者均未使用抗生素预防感染，术后24～48 h切口换药。术后患指不作外固定保护，允许近端指间关节及掌指关节主动活动。密切观察手指和创面周围血循环。术后复查X线片，如提示撕脱骨折达骨性愈合，取出克氏针，并指导患者开始DIPJ主动和被动功能锻炼。

1.4. 统计学方法

采用SPSS16.0统计软件进行分析。计量资料均符合正态分布，数据以均数±标准差表示，组间比较采用配对 t 检验；检验水准 α =0.05。

2. 结果

本组手术时间35～55 min，平均43.9 min；住院时间2～5 d，平均3.4 d。术后患者均未出现皮肤坏死、钉道感染、克氏针松动或断裂、骨折不愈合或骨不连及指甲畸形等并发症。患者均获随访，随访时间6～12个月，平均8.8个月。X线片复查示撕脱骨折均达骨性愈合，愈合时间4～6周，平均5.3周。术后6周取出克氏针后，DIPJ主动屈曲时疼痛视觉模拟评分（VAS）为1～3分，平均1.6分；被动屈曲至最大活动度时为2～5分，平均3.1分。患指DIPJ主动背伸丧失角度为（2.14±2.54）°，与术前比较差异有统计学意义（ t =52.186， P <0.001）。患指DIPJ主动屈曲角度为（79.52±6.31）°，与对应健指（81.90±5.36）° 比较，差异无统计学意义（ t =1.319， P =0.195）。术后3个月，根据Crawford ^{[

12

]} 功能评定标准评价，疗效达优11例、良9例、一般1例，优良率为95.24%。见图2 。

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图 2

A 25-year-old male patient with bony mallet finger of left middle finger (typeⅠB)

患者，男，25岁，左中指骨性锤状指（ⅠB型）

a. 术前X线片；b. 术后即刻X线片；c、d. 术后即刻患指外观；e. 术后6周取出克氏针后X线片；f～h. 术后6个月手指外观及功能

a. X-ray film before operation; b. X-ray film at immediate after operation; c, d. Appearance of the affected finger at immediate after operation; e. X-ray film after Kirschner wire removal at 6 weeks after operation; f-h. Appearance and function of the affected finger at 6 months after operation

3. 讨论

骨性锤状指本质上是关节内骨折，根据骨科手术一般原则，所有移位的关节内骨折均应解剖复位，以恢复关节面平整，获得良好功能。为追求解剖复位，临床常选择切开复位治疗骨性锤状指。然而，切开复位需过多剥离软组织，可能造成甲基质破坏等医源性损伤，进而出现不良后果 ^{[

7

,

13

]} 。而且有学者认为DIPJ为非承重关节，骨折功能复位也可能获得满意疗效 ^{[

14

]} 。Neuhaus等 ^{[

15

]} 采用闭合复位克氏针固定治疗ⅡB型骨性锤状指，认为骨折可能不需要解剖复位也能获得满意效果。在此基础上，Chen等 ^{[

16

]} 采用2枚克氏针弹性固定技术治疗骨性锤状指，通过将2枚克氏针两端缠绕在一起，实现背侧克氏针对撕脱骨块的加压固定。但是，这2枚克氏针均跨过指端且同时相向挤压，可能影响指端血循环。而且，皮外保留过长克氏针会影响患者穿衣和护理，增加了克氏针松动及骨折复位丢失的风险。之后，Gumussuyu等 ^{[

14

]} 采用了一种延长针阻挡技术来治疗急性骨性锤状指，取得良好疗效。但背侧阻挡克氏针固定往往不牢固，因固定压力不足，撕脱的骨块会分离或错位，引起复位丢失而影响后期效果。

在上述方法基础上，我们进行了一些技术上的尝试和改进。将第1枚克氏针进针位置选取在紧贴撕脱骨块背侧、DIPJ关节面近背侧缘处，既保证指骨对克氏针的把持力，又远离负重关节面，减轻了关节损伤。同时，适当增加第1枚克氏针钻入深度，以增长力臂。在钻入第2枚克氏针时，将DIPJ过伸角度调整至5°～10°，此时第1枚克氏针与纵轴成角约40°。撕脱骨折通过第1枚克氏针的回弹作用可获得更大的压力，达到骨折复位及加压固定目的，避免了关节背伸丢失，手术操作简单，固定更牢靠。但术中需注意准确把控DIPJ过伸角度，如角度过小容易造成第1枚克氏针撬拨力量不足，导致因骨折固定不牢固而复位丢失；角度过大又会使撬拨力量过度，进而压碎骨块，造成远期不良影响。Lee等 ^{[

17

]} 报道采用伸展阻滞法治疗急性骨性锤状指，结果表明延伸阻挡克氏针插入角度为40°～45° 及轻度背伸DIPJ是减少术后背伸丢失和获得骨愈合的最佳方法。本组手术方法符合该研究结论。另外，除阻挡克氏针作用于撕脱骨块的回弹压力外，本组采用的方法在患指指端没有额外作用力，局部皮肤免受过多压迫，降低了对指端及局部皮肤血运的影响。没有切口是该技术的一个明显优点，有利于保持患指正常外观。而且术后体外保留针尾较短，不影响患者穿衣、便于护理，更减少了克氏针松动的风险。本组患者术后骨折均达骨性愈合，手指功能恢复良好。

但是，以上闭合治疗技术都存在克氏针穿过DIPJ的问题，可能造成关节损伤。在克氏针钻入过程中，术者为获得良好效果往往会进行多次尝试性进针，增加了继发骨关节炎可能性 ^{[

18

]} 。而且，一旦克氏针与背侧撕脱骨块接触，骨块可能会发生旋转而导致复位丢失 ^{[

19

]} 。故术前需准确设计克氏针进针角度，术中确保操作轻柔，并结合C臂X线机透视，以达到精准复位及坚强固定，避免发生医源性创伤。术后一旦确定骨折骨性愈合，需尽早拔除固定DIPJ的克氏针，避免关节僵硬等并发症发生。另外，Karslıoğlu等 ^{[

20

]} 指出骨性锤状指中撕脱骨块伴旋转移位时会增加复位难度，并可能导致伸肌滞后、关节面错位、过早出现骨关节炎或关节僵硬。如何进一步控制骨块旋转、减少医源性甲床损伤和创伤性关节炎，是我们下一步研究目标。除此之外，第1枚克氏针在弯曲状态下存在断裂风险，因此该术式对克氏针质量要求较高。

综上述，一期闭合复位双克氏针弹性加压固定治疗Wehbe-Schneider ⅠB、ⅡB型骨性锤状指，具有操作简便、耗时较短、创伤小以及术后并发症较少等优点，可获得较好疗效。但本研究缺少对照、例数有限且部分患者随访时间较短，结论有待扩大样本量进一步研究明确。此外，撕脱骨块受到第1枚克氏针的弹性压力大小也有待后续力学试验分析。

利益冲突　在课题研究和文章撰写过程中不存在利益冲突；基金项目经费支持没有影响文章观点和对研究数据客观结果的统计分析及其报道

伦理声明　研究方案经利辛县人民医院医学伦理委员会批准（LXXRMYY-2021KY02）

作者贡献声明　官建中、李伟峰：手术方案设计及实施，文章撰写；张敬标、安庆、郑志远：数据收集整理及统计分析

Funding Statement

安徽高校自然科学研究项目（KJ2020ZD51）；蚌埠医学院研究生科研创新计划项目（Byycx21075）

Funding Statement

Natural Science Research Project of Anhui Universities (KJ2020ZD51); Graduate Research Innovation Project of Bengbu Medical College (Byycx21075)

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Articles from Chinese Journal of Reparative and Reconstructive Surgery are provided here courtesy of Sichuan University

一期闭合复位双克氏针弹性加压固定治疗Wehbe-SchneiderⅠB型及ⅡB型骨性锤状指

Treatment of Wehbe-Schneider types Ⅰ B and Ⅱ B bony mallet fingers with one-stage closed reduction and elastic compression fixation with double Kirschner wires

伟峰 李

敬标 张

庆 安

志远 郑

建中 官

结论

Abstract

Objective

Methods

Results

Conclusion

1. 临床资料

1.1. 一般资料

1.2. 手术方法

1.3. 术后处理

1.4. 统计学方法

2. 结果

3. 讨论

Funding Statement

Funding Statement

References

伟峰李

敬标张

庆安

志远郑

建中官