Anatomical And Clinical Application Study Of Modified Wrist Approach

Research BackgroundWrist disease is rare in clinic, including wrist injury and wrist lesions, many diseases need operation treatment, because of the complex relationship between the bony structures of wrist, while the rich soft tissue structure of ligament and other very important make operation treatment more difficult. There was a correlation between the wrist operation approach choices of kinds of diseases, the wrist is an important site connected forearm and palm, finger, operation directly affects the success of the wrist play coordination, stability and support functions of the hand. After diagnosis, wrist disease detailed preoperative examination, treatment is also easier. The classical approach of operation has a dorsal approach, volar, lateral approach and the medial approach. With the understanding of wrist disease deepens, operation treatment also change a lot. To accumulate, clinical very careful before carry out operation treatment of the statistical research method, effectively summarizes the research result of experience. A prospective significance of basic research results of clinical effect of the operation of the wrist.Anatomy of the wrist has been developed to a fine stage, under a microscope wrist surrounding structures (nerves, blood vessels, ligaments) of course, branches, degree of thickness measurements were observed. However, most of these studies did not improve clinical and surgical approaches linked to the study of the anatomy of the wrist fine applies wrist improved surgical approach or design more effective approach easier to operate, it will have a higher clinical guidance.Anatomy of the wrist has been developed to a fine stage, under a microscope wrist surrounding structures (nerves, blood vessels, ligaments) of course, branches, degree of thickness measurements were observed. However, most of these studies did not improve clinical and surgical approaches linked to the study of the anatomy of the wrist fine applies wrist improved surgical approach or design more effective approach easier to operate, it will have a higher clinical guidance.Unstable distal radius and ulna fractures are also common compression plate for wrist fracture type, volar fixation is the main surgical treatment, dorsal fractures can also be treated volar directly volar approach and a T-shaped plate fixation of distal radius fractures support. Forearm flexor tendon surgery must be approved by the clearance to enter, need to cut part of the flexor retinaculum (transverse carpal ligament) is revealed to be able to complete the radiocarpal articular surface, significantly increased the time to reveal the fracture site, while the distal radius and ulna distal ulnar half the fracture revealed poor situation, but also increases the chances of the median nerve injury and the difficulty of fractures reset.ObjectiveIn this study, through the study of fine anatomical wrist nerve, surgical approach to classic wrist Traveling conduct a more precise positioning and determine the surface between the extent of tissue damage minimal approach. And the surgical approach and design a more reasonable approach is applied after surgery improved clinical treatment, compared to the traditional surgical approach to intraoperative treatment of clinical cases of the same type of situation and revealed postoperative recovery. Expected use of improved surgical approach or innovative design surgical approach will reduce the side injury surgery, get a good exposure of the surgical field, thereby shortening the operation time, promote the rehabilitation of the disease after surgery.In anatomical research, to be under the microscope of nerve wrist doing fine dissected nerve, branches, diameter and the wrist joint dominance, determine the blank area (relatively safe area) nerve Traveling through simulation part of the surgical approach and measurement data for clinical studies provide anatomical basis for improved wrist surgery approach.In the clinical study, we intend opponent scaphoid fracture of the dorsal surgical approach to make improvements, and with classical dorsal approach, volar scaphoid fracture treatments were compared to assess three surgical approaches clinical and functional scores, to explore more suitable for the treatment of severe dislocation and dislocation associated with fracture of the scaphoid bone surgical approach. In another part of the clinical studies for the feet, distal radius fractures volar surgical field exposure problem, we intend to establish an improved dual-channel wrist palmar surgical approach, and the traditional direct volar compares to explore more suitable for foot, distal radial fractures of the surgical approach.Methods1. Anatomical methodsFourty cases of adult cadaveric upper extremity specimens, about half and half, wrist skin intact, no wrist and tendon injuries. Dissected and observed (under a microscope) superficial radial nerve and its branches, dorsal branch of the ulnar nerve wrist disposable wrist dorsal wrist support, posterior interosseous nerve branch wrist, forearm lateral cutaneous nerve, anterior interosseous nerve, median nerve palmar cutaneous branch of ulnar nerve deep branch and trunk dominate joint volar wrist support. The number of observation of each branch of the wrist joint, origin and issue parts, and use an accuracy of 0.02 mm caliper measurement of the diameter of the nerve. The following data were measured by using a caliper:shallow superficial radial nerve segment length (superficial radial nerve branches to the distance between the light at the point); distance radial styloid shallow superficial radial nerve to point out; radial styloid to the radial nerve superficial branch of the branch point distance; a point to the superficial radial nerve epicondyle of the humerus and the vertical distance of the most salient points of the radial styloid point superficial radial nerve deep section chief. Measuring the ulnar styloid and dorsal branch of the ulnar nerve in the distance.Ten fresh cadavers upper extremity specimens, dual-channel analog wrist palmar surgical approach, the palm side of the wrist flexor carpi radial longitudinal incision made between the tendon and the tendon to the radial, ulnar bypass into the subcutaneous carpal tunnel structure, via a modified two-channel approach to the observation radius, ulna distal exposure.3 cm above the wrist crease level, measuring the radial distance of exposure pathways maximum lateral traction, pulling the maximum lateral ulnar pathways of exposure distance.2. Clinical methods:2.1 Improved surgical approach dorsal carpal scaphoid fracture treatment applied clinical researchBetween 2011-2014, will we treated 48 cases diagnosed as acute scaphoid fractures in patients with a displaced fracture as a serious study. Including 46 patients, 48 of the wrist; 34 cases of males and 12 females; mean age was 33.1 years old. Using wrist anteroposterior and lateral X-ray used to evaluate the diagnosis. X-ray five patients failed to find the fracture, and further confirmed by computed tomography. Were randomly divided into three groups,16 cases in each group, dorsal surgical approach group, volar group and modified dorsal approach groups. Surgical methods as follows:2.1.1 dorsal surgical approachThe patients with brachial plexus block or general anesthesia placed in the supine position, using the upper limb tourniquet to stop bleeding. Since the first dorsal metacarpal base diagonally along the proximal carpal do snuffbox central 5cm incision, to protect the cephalic vein, superficial radial nerve important structures, such as the radial artery. The tendon stretch to both sides of the longitudinal incision posterior capsule revealed scaphoid fracture area, the scaphoid fracture reduction under direct vision guided needle penetration along the central axis of the scaphoid, confirm the position of the guide pin is completed under fluoroscopy. Guide pin through drilling, screwing Herbert screws. Finalize the fixed position of the screw under fluoroscopy. After the local irrigation, suture the skin. Using a short arm cast immobilization of the wrist in a neutral position.2.1.2 Volar surgical approachThe patients with brachial plexus block or general anesthesia placed in the supine position, using the upper limb tourniquet to stop bleeding. Volar wrist do arc about 5cm incision convex arc to the radial side, to protect the radial artery, the proximal part of the transverse carpal ligament cut, the inner pull to the ulnar carpal tunnel structure, longitudinal incision of the joint capsule, exposing the boat bone fractures, the wrist straight and slightly ulnar flexion to penetrate from the dorsal navicular tuberosity. Before the adoption of the fracture line, from distal to proximal fracture line adjustment pressed to determine whether the location of fracture dislocation in flexion and the longitudinal axis of the scaphoid by Kirschner of fluoroscopy. Herbert also uses screws. After the local irrigation, suture the skin. Using a short arm cast immobilization of the wrist in a neutral position.2.1.3 Modified dorsal surgical approachThe patients with brachial plexus block or general anesthesia placed in the supine position, using the upper limb tourniquet to stop bleeding. Placed straight wrist position, the first boat in the perspective of the distal fracture fragment found and marked, with a diameter of 0.8mm Kirschner wire through the distal scaphoid fracture block will be fixed in a head-shaped bone in the direction of the lateral view, Kirschner determine the location and scaphoid fractures of the distal block under fluoroscopy. Wrist flexion bit longer fluoroscopy proximal scaphoid fracture fragments found and marked, along the axis of the scaphoid after penetration of the needle guide and the distal fragment under fluoroscopy after bit penetration, requires accurate as possible, to avoid repeated needle, perspective scaphoid fractures observed conditions and guide the needle position, the back side of the entrance to do in the guide pin 5mm incision, blunt dissection poke tendon. Measure the length of the screw, the Herbert screw under the guidance of the guide pin through the dorsal screwed fixed. After the local irrigation, suture the skin. Using a short arm cast immobilization of the wrist in a neutral position. Short arm cast immobilization of the wrist in a neutral position.Three groups using plasterboard fixed wrist two weeks. Using active auxiliary exercises encourage patients immediately after surgery. Explicitly allow bone healing after weight-bearing exercises. X-ray examination in three directions to determine bone healing; goniometer to measure the wrist range of motion; dynamometer grip detect patients; patients pinch dynamometer pinch force detection function; the rated wrist evaluation form (patient-rated wrist evaluation, PRWE) and Mayo wrist scoring system to evaluate the function of the patient’s wrist.2.2 Dual approach of treating fractures of the distal radius and ulnaBetween 2011-2014, will we treated 67 cases diagnosed with fractures of the distal radius and ulna as a research object. Of which 30 males and 37 females; aged 21 to 59 years, mean age 52.34 years; 29 cases left side, the right side of the 38 cases. Randomly divided into two groups, palmar direct approach group 35 cases, wrist palmar dual channel approach group 32 cases. Surgical methods as follows:2.2.1 Volar direct approachPatient supine outreach limb, brachial plexus or general anesthesia, the forearm was completely screwed position. Along the palm side of the forearm flexor carpi radialis tendon edge for 5-7cm long incision, wrist stripes at the deadline. The radial wrist flexor tendons and the median nerve and other structures to pull to the ulnar, radial artery and other structures to pull to the radial side. The pronator muscle attachment in the radial side of the cut. As subperiosteal stripping to expose the fracture. Incision over the wrist crease can clearly reveal the articular surface of the distal radius. Fracture fragments were reset, restore radial length, palmar angle and ulnar deviation. If necessary, with a fine Kirschner temporary maintenance of reduction through the fracture line. Finally, the distal radius volar anatomic locking plate fixation of fractures of the metal layers and the wound is closed after washing, plaster immobilization in a neutral wrist position.2.2.2 Dual wrist palmar approachVolar wrist tendon along the radial ulnar flexor carpi 5 cm longitudinal incision made to the radial, ulnar carpal tunnel bypass structure into the skin, the radial side of the channel:the radial wrist flexor tendon to the radial side of the stretch, in the depths of the radial carpal tunnel structure lateral separation to pronator muscle, longitudinal cut pronator muscle exposed to the palm side of the distal radius. Ulnar channels:the ulnar tendon to stretch, in the ulnar carpal tunnel from the deep part of the structure to the pronator muscle, the pronator muscle stripping along the bone surface exposed distal radial ulnar half. For periosteal stripping down to reveal the fracture and the articular surface of the distal radius, not carpal tunnel decompression. Fracture fixation operation via two channels, the same volar distal radius anatomical locking metal plate, layer by layer after washing the wound closed, plaster immobilization in a neutral wrist position.Record the start of surgery to the time required to fully reveal the fracture site; operative time; pronator muscle repair rate. The incidence of median nerve irritation. One day after the first check to the patient complained of three and a half fingers radial distribution of the median nerve numbness, pain reduction as a positive standard acupuncture. Motor function and radiographic indicators measuring postoperative grip strength meter hydraulic dual grip strength was measured at 12 months. After two wrist range of motion detection 12 months through Efilm Workstation image measurement software system. Suffering from wrist X-ray detection of two palm inclination, ulnar deviation and radial height. Referring Gartland-Werley wrist surgery clinical assessment criteria:excellent 0-2 points; good 3-8 points; available from 9 to 21 points; bad 21 points.Results1. Anatomical findingsIn the dominant wrist nerves among the posterior interosseous nerve terminal branches mainly dominated radiocarpal joint dorsal and dorsal wrist, while the nerve branches also dominated the second, third and fourth carpometacarpal joint. Radiocarpal joint, the radial side of the wrist, and the first carpometacarpal joint governed by the lateral cutaneous nerve of the forearm. Superficial radial nerve branches are the main source of innervation of the first metacarpal area, the first and second carpometacarpal joint innervation is also superficial radial nerve involvement. Deep branch of the ulnar nerve and ulnar wrist participate fourth, fifth carpometacarpal joint innervation. Innervation of the palm side of the wrist did not find major nerve involvement. In the palm side of the wrist that is at the bottom of the deep surface of the carpal tunnel, the anterior interosseous nerve involvement disposable wrist joint, the transverse carpal ligament is issued by a branch of the median nerve palmar branch of domination, the ulnar nerve is a triangular bone and around the wrist and palm ulnar joint The main source of innervation. Volar wrist dual channel approach 3 cm above the wrist crease level, the maximum lateral traction radial path expose distance (3.0±0.29)cm, maximum lateral traction exposed ulnar path distance (2.3±0.26)cm. Radial path can effectively expose the radial side of the distal radius and a half, but the exposed distal radial ulnar half is more difficult, and ulnar path can effectively expose the distal radius and ulna distal ulnar half.2. Clinical findings:2.1 Improved surgical approach dorsal carpal scaphoid fracture treatment applied clinical researchMean follow-up time of the dorsal surgical approach group was (16.7±8.3) months. PRWE score was (1.2±1.6), Mayo wrist score display (89.3±10.7),10 patients are the best; good four cases; two cases of satisfaction. Measuring the average moving angle:buckling up (63.2±9.6)°, stretching up (61.3±11.5)°, radial flexion up (26.6±8.3)°, ulnar flexion up (45.2±14.9)°. Grip strength tests showed (22.7±8.4) kg; pinch strength tests show that (10.9±1.9) kg. Patients with bilateral fractures treated with dorsal surgical approach.The average follow-up time of volar surgical approach group are (17.8±9.9) months. PRWE score was (1.1±1.2), Mayo wrist score display (91.6±7.4),11 patients are the best; good four cases; one case of satisfaction. Measuring the average moving angle:buckling up (59.2±7.4)°, stretching up (60.4±9.5)°, radial flexion up (31.3±11.8)°, ulnar flexion up (51.3±15.6)°. Grip strength tests showed (25.5± 8.9) kg; pinch strength tests show that (11.3±2.1) kg.The average follow-up time modified dorsal surgical approach group was (18.6 ±8.4) months. PRWE score was (1.4±1.2), Mayo wrist score display (98.3±4.2),13 patients are the best; good three cases. Measuring the average moving angle:buckling up (64.2±4.4)°, stretching up (62.1±6.1)°, radial flexion up (35.6±10.2)°, ulnar flexion up (54.3±10.6)° grip strength tests show that (29.7±8.3) kg; pinch strength tests show that (11.4±2.2) kg.In clinical function evaluation, dorsal surgical approach group and volar surgical approach group no significant statistical difference. Improved surgical approach dorsal and volar group compared wrist flexion significantly improved the ability of patients (P=0.0271); modified dorsal surgical approach compared with traditional surgical approach dorsal group, in the radial lateral flexion (P=0.0103), pinch strength evaluation (P=0.0002), Mayo score (P=0.0039), time to return to work in patients (P=0.0169) were significantly improved and enhanced. The injured side of the experimental group and comparative analysis uninjured side was also no significant difference was statistically significant two months after the surgery(P> 0.05).2.2 Clinical application of fracture of the distal radius and ulna volar wrist Dual therapy approachResults There were no observed wound infection, after review of wrist X-ray, all patients without palmar cutaneous branch of the median nerve, no thenar branch of the median nerve damage, no injuries and wrist flexor tendon elongation thumb tendon rupture, surgery after loosening the screws and also no significant loss of reduction. The first day after surgery, the direct volar median nerve irritation occurs eight cases, the performance of the radial side of the hand hypoesthesia three and a half fingers median nerve distribution area and numbness. Dual-channel approach only two cases occur, the difference was statistically significant (P<0.01).All patients with neurological symptoms disappear within two months, after a review of the year because no postoperative compression of the median nerve and the line two cases of carpal tunnel decompression. Fracture line disappeared while no local tenderness and vertical percussion pain standard for fracture healing. Were bone fracture healing time of 10 to 12 weeks, with an average 10.9 weeks and 11 patients had a second operation to remove a fixed year, the two groups revealed the fracture time, operation time and pronator muscle repair rate compared to the dual-channel Road revealed the fracture time and operation time was significantly less than direct volar(P<0.01).After 12 months in both groups range wrist activity, in addition to radial deviation vary slightly outside the other indexes difference was not statistically significant. Two groups of patients grip strength and radiographic measurements were not significantly different (P> 0.05).Two groups of patients Gartland-Werley evaluation results dual channel approach group Gartland-Werley score was (2.97±2.19) points,93.75% of the direct superior volar surgical group Gartland-Werley score was (3.27±2.28) points, good rate of 91.43% two sets of residual deformity, subjective evaluation and objective evaluation, complications, total score and scores grading and excellent rate, the difference was not statistically significant (P> 0.05).Conclusion1、After fine anatomical study of the wrist innervation, we by determining the blank area (relatively safe area) nerve Traveling, design approach path to improved surgery, to avoid damage nerves and wrist support, integrated into the concept of minimally invasive.2、Successfully designed a scaphoid fracture treatment method modified dorsal surgical approach, used in clinical and classical dorsal approach, volar scaphoid fracture treatment methods were compared, evaluated clinical features are an advantage.3、In the anatomy of the wrist in dual-channel analog wrist palmar surgical approach and confirmed its feasibility in clinical and traditional direct approach after volar comparison.4、Improved dual-channel wrist palmar surgical approach to the successful solution clinically feet, distal radius fractures volar surgical field exposure problem, with reliable clinical operability and achieved good clinical efficacy.Innovations:1. Fine anatomical wrist innervation modified surgical approach helps determine the path of surgical anatomy simulation approach for the improvement of surgical approach provides a reliable basis.2. Improved dorsal surgical approach to treat severe and accompanied by dislocation displaced scaphoid fractures, especially fractures of the proximal 1/3 to 1/2 has its unique advantages. The complex fracture instability becomes difficult to reset approximate stability of the fracture, while incorporating the concept of minimally invasive, surgery has a small side injury, genetically related to boat damage, less bleeding, etc. for.3. Improved Dual wrist palmar surgical approach to the successful solution of foot, distal radius fractures volar distal radial ulnar half of blind exposure problem, you can complete treatment of fractures of the region under direct vision operation. Reducing the median nerve in the carpal tunnel and the structure of the stretch, reduce the incidence of postoperative complications. Successfully achieved by a surface incision surgery implement two channels, into the concept of minimally invasive operation, in a more effective exposure of the operative field premise, as far as possible to reduce the damage to a minimum.4. After anatomical experiments and clinical trials to verify the improved wrist surgical approach is feasible and effective, so that a good complement and improve on the classic surgical approach.