中国组织工程研究

中国组织工程研究 ›› 2023, Vol. 27 ›› Issue (31): 4921-4925.doi: 10.12307/2023.682

• 骨与关节生物力学 bone and joint biomechanics •    下一篇

背侧克氏针增强AO C型桡骨远端骨折尺背侧骨折块稳定性的有限元分析

殷  浩1，陈  光1，李  燕1，周恩昌2，宁仁德 1，3   

  1. 1安徽医科大学第三附属医院骨科，安徽省合肥市   230061；2聊城市第二医院，山东省临清市   252600；3西藏自治区山南市人民医院骨科，西藏自治区山南市   856000
  • 收稿日期:2022-07-18 接受日期:2022-10-14 出版日期:2023-11-08 发布日期:2023-01-30
  • 通讯作者: 宁仁德，博士，主任医师，教授，博士生导师，安徽医科大学第三附属医院骨科，安徽省合肥市 230061；西藏自治区山南市人民医院骨科，西藏自治区山南市 856000
  • 作者简介:殷浩，男，1977年生，河南省固始县人，2008年苏州大学毕业，博士，主任医师，主要从事人工关节及复杂创伤、生物力学方面的研究。
  • 基金资助:
    西藏山南市科技计划项目(SNKJJH2020203)，项目负责人：宁仁德

Finite element analysis of dorsal Kirschner wire for enhancing the stability of the dorsal ulnar fracture fragment in AO C type distal radial fractures

Yin Hao1, Chen Guang1, Li Yan1, Zhou Enchang2, Ning Rende1, 3   

  1. 1Department of Orthopedics, Third Affiliated Hospital of Anhui Medical University, Hefei 230061, Anhui Province, China; 2Liaocheng Second Hospital, Linqing 252600, Shandong Province, China; 3Department of Orthopedics, Shannan People’s Hospital, Shannan  856000, Tibet Autonomous Region, China
  • Received:2022-07-18 Accepted:2022-10-14 Online:2023-11-08 Published:2023-01-30
  • Contact: Ning Rende, MD, PhD, Chief physician, Professor, Doctoral supervisor, Department of Orthopedics, Third Affiliated Hospital of Anhui Medical University, Hefei 230061, Anhui Province, China; Department of Orthopedics, Shannan People’s Hospital, Shannan 856000, Tibet Autonomous Region, China
  • About author:Yin Hao, MD, PhD, Chief physician, Department of Orthopedics, Third Affiliated Hospital of Anhui Medical University, Hefei 230061, Anhui Province, China
  • Supported by:
    Tibet Shannan Science and Technology Plan Project, No. SNKJJH2020203 (to NRD)

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摘要：

文题释义：

桡骨远端骨折：约占全身骨折的1/6，主要好发于青年患者和老年患者，青年患者主要是由于运动或交通的高能量损伤所致，并常常合并软骨和韧带损伤；老年人大多由低能量损伤导致的骨质疏松性骨折，且骨折严重程度不一，容易出现复位后的丢失。随着社会的老龄化加剧，作为最常见的骨质疏松性骨折代表，如何实现此类患者骨折后快速功能恢复、无明显残留后遗症是当前临床骨科医生所面临的一个重要挑战。
尺背侧骨折块：属于桡骨远端骨折三柱分型中的中柱，其包括桡月关节面和下尺桡骨关节面，若尺背侧骨块未能得到妥当处理，将导致桡腕关节、下尺桡关节的疼痛、无力、活动受限、脱位和创伤性关节炎等一系列并发症的发生。因此桡骨远端粉碎性骨折中尺背侧骨折块的处理极为关键。

背景：波及尺背侧骨折块的桡骨远端骨折属于不稳定型骨折，属于AO分型的23C型、三柱分型中波及中间柱的骨折，尺背侧骨折块不能得到有效固定，将影响桡腕关节和下尺桡关节的稳定性，而当前单纯掌侧钢板固定尺背侧骨折块的作用有限，若附加背侧钢板虽然固定效果好，但将增加手术创伤、导致肌腱损伤粘连，并提高了治疗费用，不符合当前疾病诊断相关分组的政策，附加背侧克氏针固定是个较为可行的方案。
目的：通过建立AO/ASIF 23-C1 桡骨远端骨折的有限元模型，比较掌侧锁定钢板和掌侧锁定钢板附加背侧克氏针两种内固定方式生物力学稳定性的差异，尤其关注尺背侧骨折块的固定效果，为临床应用提供参考。
方法：利用逆向建模技术，将42岁男性志愿者健康前臂CT数据及内固定数据导入相关软件，分别建立AO/ASIF 23-C1 桡骨远端骨折掌侧锁定钢板和掌侧锁定钢板附加背侧克氏针内固定三维有限元模型。对模型分别施以100 N轴向载荷、1 Nm的弯曲及扭转载荷，比较两组尺背侧骨折块最大位移、内固定上最大Von Mises 应力及应力分布等指标。

结果与结论：①两种固定方式下，内固定上的应力均2-10倍于骨骼，符合骨折早期稳定的要求；②在3种不同载荷下，两组间应力峰值比较，无论是骨骼上还是内固定上的应力均差别不大( < 30%)；在轴向载荷下内固定上的应力峰值为骨骼的三四倍；但在弯曲载荷下，内固定上的应力峰值为骨骼的8-10倍；而在扭转载荷下内固定上的应力峰值仅为骨骼的2倍；③在轴向载荷下，两组间尺背侧骨折块的最大位移极小且差别不大，仅为0.056 mm和0.047 mm，表明骨折块的稳定性好；在弯曲载荷下，单一钢板固定组最大位移为克氏针固定组的2.4倍；在扭转载荷下，单一钢板固定组最大位移为克氏针固定组的2.7倍；④提示附加克氏针的掌骨锁定钢板能更好地固定尺背侧骨折块，应力分布更均匀，提高了固定强度，且未明显增加手术费用，更适合于当前疾病诊断相关分组控费下涉及尺背侧骨折块的桡骨远端骨折的治疗。

https://orcid.org/0000-0003-1181-0490 (殷浩) 

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

关键词: 桡骨远端骨折, 内固定, 掌侧锁定钢板, 克氏针, 位移, 应力, 生物力学, 有限元分析

Abstract: BACKGROUND: Distal radial fracture involving dorsal ulnar fragment type belongs to unstable fractures, AO classification of 23C type and the middle column fractures of three-column classification. If dorsal ulnar fragment cannot be effectively fixed, it will affect the stability of radial joints and ulnar radial joints. The fixation effect of dorsal volar plate alone on dorsal ulnar fragment is limited. Although the fixation effect of dorsal volar double plate is effective, it increases the trauma and treatment cost, which is not in line with the current Diagnosis Related Groups policy. The addition of dorsal Kirschner wire fixation may be a relatively feasible plan.  
OBJECTIVE: A finite element model of AO/ASIF 23-C1 distal radial fracture was established to compare the differences in biomechanical stability between volar locking plate and volar locking plate plus dorsal Kirschner wire, especially focusing on the fixation effect of dorsal ulnar fragment, providing a reference for clinical application.
METHODS: Using reverse modeling technology, the CT data of healthy femur of a 42-year-old male and internal fixation data were imported into relevant software to establish three-dimensional finite element models of AO/ASIF 23-C1 distal radial fractures with volar locking plate and volar locking plate with dorsal Kirschner wire. The models were subjected to 100 N axial stress, or 1 Nm bending or torsional stress, respectively. The maximum displacement, maximum Von Mises stress and stress distribution of dorsal ulnar fragment were compared between the two groups.  
RESULTS AND CONCLUSION: (1) The stress on the internal fixation was 2-10 times that on the bone under the two fixation methods, which met the requirements of fracture fixation. (2) Under the three different loads, there was no significant difference between the two groups in the stress peaks of both bone and internal fixation (< 30%). Under an axial load, the peak stress on the internal fixation was 3-4 times that on the bone. However, under bending load, the peak stress of internal fixation was 8-10 times that of bone, while under torsion load, the peak stress of internal fixation was only twice that of bone. (3) Under an axial load, the maximum displacements of the dorsal ulnar fragment between the two groups were very small and the difference was small, only 0.056 mm and 0.047 mm, respectively, indicating good stability of the fragment. Under bending load, the maximum displacement of single plate group was 2.4 times that of Kirschner wire group. Under torsion load, the maximum displacement of the single plate group was 2.7 times that of the Kirschner wire group. (4) It is indicated that the volar locking plate with Kirschner wire can more effectively fix the dorsal ulnar fracture fragment, with more uniform stress distribution, improve the fixation strength, and does not significantly increase the treatment cost. It is more suitable for the treatment of distal radial fractures involving the dorsal ulnar fracture fragment under the current Diagnosis Related Groups policy.

Key words: distal radius fracture, internal fixation, volar locking plate, Kirschner wire, displacement, stress, biomechanics, finite element analysis

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