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【转载】[骨科英语]flexor carpi radialis (FCR)  

2015-10-29 11:18:12|  分类: 骨科英语 |  标签: |举报 |字号 订阅

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·  A longitudinal incision is made over the distal aspect of the flexor carpi radialis (FCR) tendon. The volar aspect of the FCR sheath is incised and the FCR tendon is retracted ulnarly. The bed of the sheath is then incised longitudinally.The volar and dorsal sheaths of the FCR tendon are incised. The radial artery is retracted toward the radial side. The FCR tendon is retracted ulnarly, thereby protecting the palmar cutaneous branch of the median nerve and the median nerve proper.

·  The PQpronator quadratus is released from the radial side, allowing visualization of the distal radius. A plate can be slid in a minimally invasive technique beneath the PQ for extra-articular fractures.

·  The flexor pollicis longus (FPL) tendon lies just beneath the FCR sheath. Retraction of the FPL tendon ulnarly will reveal the deep layer of the palmar approach and hence the pronator quadratus (PQ) .

·  The PQ is released sharply from the radius, leaving a small cuff of tissue radially. It is reflected back as an ulnar-based flap. Care must be taken not to detach the palmar extrinsic radiocarpal ligaments .

·  The use of the FCR for the palmar approach keeps the radial artery safely out of the surgical plane just radial to the dissection .The palmar cutaneous branch of the median nerve is only at risk if the dissection strays to the ulnar side of the FCR .

·  The approach allows for exposure of the entire volar distal radius and can be used for most fractures.

·  Occasionally, particularly for fractures, treated in delayed fashion, dissection can be carried out radial to or below the radial artery, and a brachioradialis tenotomy can then be performed. The brachioradialis tenotomy will release one of the main deforming vectors on the fracture. Care must be taken to avoid injury to the first dorsal compartment during this radial dissection .

·  The patient is positioned supine with the involved extremity draped free and centered on a radiolucent hand table .A weight system with sterile rope is seen projecting from the end of the hand table in ; this aids in some complex fractures.

·  The table is set up to allow frequent radiographic evaluation. A mobile C-arm is used for every case.

·  A tourniquet is placed around the upper arm. One or two towels rolled and held in place with a plastic sticky drape are useful to position the wrist and hand on.

·  The surgeon usually sits in the patient’s axilla, but this is not an absolute rule.

·  Avoid releasing the strong volar carpal ligaments and destabilizing the radiocarpal joint.

·  Reduction of the intra-articular fracture components can be judged with the aid of intraoperative fluoroscopy. If any question remains about the intra-articular reduction, a separate mini–dorsal arthrotomy can be performed to allow direct visualization of the intra-articular reduction.

·  Alternatively, intra-articular reduction can be assessed through the volar exposure through the fracture site by supinating the distal fragment and hand relative to the proximal fragment and forearm. Reduction of the joint is then assessed in retrograde fashion through the proximal aspect of the distal fracture fragments.

·  A locking plate is positioned onto the volar aspect of the radius.

·  Volarly placed screws are at risk of causing tendon rupture on the dorsal radius. The lateral radiograph gives a false impression of screw containment inside bone due to Lister’s tubercle when, in fact, they may have overpenetrated the dorsal cortex. All screws should be short of the dorsal surface as checked with a depth gauge, not radiographs alone.

·  The DRUJ must be closely examined after plate application. Although the plates can be placed quite ulnar in position on the volar side with little worry about pronation and supination, care must be taken that the screws do not enter the DRUJ. Some plates have an exaggerated spread of screws to incorporate the fragment.

·  The patient is placed in a below-the-elbow splint in surgery. Only rarely is an above-the-elbow splint used.

·  The splint is changed to a cast, after suture removal and wound check, for a total of 5 weeks. If locking plates have been used to fix an extra-articular or stable-after-fixation intra-articular fracture, then total cast time is shortened to 4 weeks

·  A sling is used for 1 week, then removed if possible.

·  If present, wires are removed at 4–5 weeks postoperative in the clinic.

·  An occupational therapy splint is used at 4–6 weeks.

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