Both-bones fractures of the forearm are diaphyseal fractures that simultaneously involve both the ulna and the radius. According to the AO documentation these represent 7% of all fractures (Rüedi et al, 2000). Fractures with simple fracture (type A) or wedge (type B) fractures are often the result of indirect trauma mechanisms, while complex fractures (type C) are the result of high energy trauma (Patel et al, 2015) . They are easily diagnosed given the obvious deformation of the arm at the inspection, however a complete preoperative diagnostic procedure involves two radiographs according to the two orthogonal planes including the elbow and wrist to exclude associated injuries. Given the biomechanical importance of the anatomical complex of the forearm, the treatment of biosseous fractures of the forearm in adults is generally surgical: it is necessary to pay particular attention to the anatomical restoration of the interosseous space and the physiological radius curvature (Jupiter et al, 2008) . Considering the probability of loss of function after these fractures, the open reduction and internal synthesis (ORIF) with plate and screws represents the gold standard of therapy and is therefore used to manage most of the biosseous fractures of the forearm (Perren, 2002). Compression plating of the radial and ulnar shaft is appropriate for the management of simple fracture patterns; the use of bicortical screws and compression of the ends of the fracture allow the creation of an environment of almost zero deformation, favoring direct bone healing (AO Foundation, 2014); 3.5 mm plates with six bicortical screws are currently used, three proximal and three distal to the fracture (Stoffel et al, 2004). Comminuted fractures should be addressed with the intention of optimizing rather than minimizing deformation; a deformation environment of 2% to 10%, which favors the formation of the bone callus, can be created with the use of bridge plates (Sanders et al, 2002). The biosseous fractures of the forearm have always been exposed through two separate incisions. Radium can be exposed with a dorsal approach (Thompson) or fly (Henry); this decision is based on the position of the fracture and / or on the presence of traumatic wounds that could limit the surgical incision (Schulte et al, 2014). The ulna is exposed through a separate incision along its subcutaneous margin (Sanders et al, 2002). According to the literature, attempting to approach biosseous fractures of the forearm with a single surgical incision would increase the risk of nerve injury and radio-ulnar synostosis (Vince et al, 1987. Bauer et al, 1991). Recently, a single fly approach has been devised to expose the biosseous fractures of the forearm (Procaccini et al, 2019). The aim of the following study is to compare the anatomical and functional results between the single access and the double access technique. A retrospective observational study was designed on 47 patients, of whom 27 received treatment with double surgical access while the remaining 20 with single access fly. In conclusion, this study suggests that in the treatment of biosseous fractures of the forearm the single access fly technique has a clinical efficacy comparable to the double access; it is also associated with a shorter average fracture consolidation time and a lower post-operative complication rate.
Le fratture biossee dell’avambraccio sono fratture diafisarie che coinvolgono contemporaneamente sia l’ulna che il radio. Secondo la documentazione AO queste rappresentano il 7% di tutte le fratture (Rüedi et al, 2000). Le fratture con rima di frattura semplice (tipo A) o a cuneo (tipo B) sono spesso il risultato di meccanismi di traumi indiretto, mentre le fratture complesse (tipo C) sono il risultato di traumi ad alta energia (Patel et al, 2015). Sono facilmente diagnosticabili vista la evidente deformazione del braccio all’atto ispettivo, tuttavia un completo iter diagnostico preoperatorio prevede due radiografie secondo i due piani ortogonali comprendenti il gomito e il polso per escludere lesioni associate. Vista l’importanza biomeccanica del complesso anatomico dell’avambraccio, il trattamento delle fratture biossee dell’avambraccio negli adulti è generalmente chirurgico: è necessario porre particolare attenzione al ripristino anatomico dello spazio interosseo e della curvatura fisiologica del radio (Jupiter et al, 2008). Considerando la probabilità di perdita di funzione dopo queste fratture, la riduzione a cielo aperto e sintesi interna (ORIF) con placca e viti rappresenta il gold standard della terapia e viene utilizzata pertanto per gestire la maggior parte delle fratture biossee dell’avambraccio (Perren, 2002). Il placcaggio in compressione della diafisi radiale e ulnare è appropriato per la gestione di semplici pattern di frattura; l’utilizzo di viti bicorticali e la compressione delle estremità della frattura, consentono la creazione di un ambiente di deformazione quasi zero, favorente la guarigione ossea diretta (AO Foundation, 2014); attualmente sono utilizzate placche da 3,5 mm con sei viti bicorticali, tre prossimali e tre distali alla frattura (Stoffel et al, 2004). Le fratture comminute dovrebbero essere affrontate con l’intenzione di ottimizzare piuttosto che minimizzare la deformazione; un ambiente di deformazione dal 2% al 10%, che favorisce la formazione del callo osseo, può essere creato con l’utilizzo di placche a ponte (Sanders et al, 2002). Le fratture biossee dell’avambraccio sono sempre state esposte attraverso due incisioni separate. Il radio può essere esposto con un approccio dorsale (Thompson) o volare (Henry); questa decisione si basa sulla posizione della frattura e / o sulla presenza di ferite traumatiche che potrebbero limitare l’incisione chirurgica (Schulte et al, 2014). L’ulna è esposta attraverso un’incisione separata lungo il suo margine sottocutaneo (Sanders et al, 2002). Secondo la letteratura, tentare di approcciare le fratture biossee dell’avambraccio con una singola incisione chirurgica aumenterebbe il rischio di lesioni nervose e di sinostosi radio-ulnare (Vince et al, 1987. Bauer et al, 1991). Recentemente, è stato ideato un singolo approccio volare per esporre le fratture biossee dell’avambraccio (Procaccini et al, 2019). L’obiettivo del seguente studio è confrontare i risultati anatomici e funzionali tra la tecnica a singolo accesso e quella a doppio accesso. È stato disegnato uno studio osservazionale retrospettivo su 47 pazienti, di cui 27 hanno ricevuto il trattamento con doppio accesso chirurgico mentre i restanti 20 con singolo accesso volare. In conclusione, questo studio suggerisce che nel trattamento delle fratture biossee dell’avambraccio la tecnica di singolo accesso volare presenta un’efficacia clinica comparabile al doppio accesso; inoltre è associato ad un minor tempo di consolidazione medio della frattura e a un minore tasso di complicanze post-operatorie.
Frattura biossea avambraccio: singolo accesso versus doppio accesso. Studio prospettico clinico e radiografico.
MARTINI, FRANCESCO
2019/2020
Abstract
Both-bones fractures of the forearm are diaphyseal fractures that simultaneously involve both the ulna and the radius. According to the AO documentation these represent 7% of all fractures (Rüedi et al, 2000). Fractures with simple fracture (type A) or wedge (type B) fractures are often the result of indirect trauma mechanisms, while complex fractures (type C) are the result of high energy trauma (Patel et al, 2015) . They are easily diagnosed given the obvious deformation of the arm at the inspection, however a complete preoperative diagnostic procedure involves two radiographs according to the two orthogonal planes including the elbow and wrist to exclude associated injuries. Given the biomechanical importance of the anatomical complex of the forearm, the treatment of biosseous fractures of the forearm in adults is generally surgical: it is necessary to pay particular attention to the anatomical restoration of the interosseous space and the physiological radius curvature (Jupiter et al, 2008) . Considering the probability of loss of function after these fractures, the open reduction and internal synthesis (ORIF) with plate and screws represents the gold standard of therapy and is therefore used to manage most of the biosseous fractures of the forearm (Perren, 2002). Compression plating of the radial and ulnar shaft is appropriate for the management of simple fracture patterns; the use of bicortical screws and compression of the ends of the fracture allow the creation of an environment of almost zero deformation, favoring direct bone healing (AO Foundation, 2014); 3.5 mm plates with six bicortical screws are currently used, three proximal and three distal to the fracture (Stoffel et al, 2004). Comminuted fractures should be addressed with the intention of optimizing rather than minimizing deformation; a deformation environment of 2% to 10%, which favors the formation of the bone callus, can be created with the use of bridge plates (Sanders et al, 2002). The biosseous fractures of the forearm have always been exposed through two separate incisions. Radium can be exposed with a dorsal approach (Thompson) or fly (Henry); this decision is based on the position of the fracture and / or on the presence of traumatic wounds that could limit the surgical incision (Schulte et al, 2014). The ulna is exposed through a separate incision along its subcutaneous margin (Sanders et al, 2002). According to the literature, attempting to approach biosseous fractures of the forearm with a single surgical incision would increase the risk of nerve injury and radio-ulnar synostosis (Vince et al, 1987. Bauer et al, 1991). Recently, a single fly approach has been devised to expose the biosseous fractures of the forearm (Procaccini et al, 2019). The aim of the following study is to compare the anatomical and functional results between the single access and the double access technique. A retrospective observational study was designed on 47 patients, of whom 27 received treatment with double surgical access while the remaining 20 with single access fly. In conclusion, this study suggests that in the treatment of biosseous fractures of the forearm the single access fly technique has a clinical efficacy comparable to the double access; it is also associated with a shorter average fracture consolidation time and a lower post-operative complication rate.File | Dimensione | Formato | |
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Tesi - Frattura biossea avambraccio.pdf
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https://hdl.handle.net/20.500.12075/1969