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Biomechanik distaler Radiusfrakturen

Grundlagenverständnis und GPS-Behandlungsstrategie bei winkelstabiler Plattenosteosynthese

Biomechanics of distal radius fractures

Basics principles and GPS treatment strategy for locking plate osteosynthesis

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Zusammenfassung

Die distale Radiusfraktur ist meist Folge eines Hyperextensionstraumas. Einwirkende Zug- und Druckvektoren, Impulsstärke, Knochenstatus und Weichteilspannung schaffen ein individuell unterschiedliches Frakturbild. Metaphysäre Stauchungsdefekte, fehlende kortikale Abstützung, ligamentäre Abriss- und Scherfragmente definieren die Frakturinstabilität. Die Dislokation des Gelenkfragments folgt den Kraftvektoren der extrinsischen Muskelgruppen.

Zur Auswahl der individuell idealen Behandlungsform hat sich die Goal-Plan-Standardized (GPS) Behandlungsstrategie bewährt. Basis ist die Bedarfsanalyse der Handgelenkfunktion und eine Beurteilung der Frakturinstabilität im CT. Das Ziel ist eine realistische subjektive Erwartungshaltung eingeschätzt durch den Patienten und Behandler. Der Behandlungsplan umfasst die Risiko-Nutzen-Abwägung und Verfahrenswahl. Die Standards der Operationsverfahren und Nachbehandlung basieren auf biomechanischen Erkenntnissen. Der Therapieansatz zur maximal stabilen Plattenosteosynthese liegt in der Neutralisation der dislozierenden Kraftvektoren. Er soll eine frühfunktionelle Nachbehandlung ermöglichen. Eine unidirektionale Instabilität kann mithilfe der winkelstabilen palmaren Plattenosteosynthese auch indirekt ausreichend neutralisiert werden. Eine multidirektionale Instabilität wird nach dem Säulenprinzip mit der Mehrfachplattenosteosynthese neutralisiert. Distale Scher- und Abrissfrakturen können fragmentspezifisch minimal adressiert werden.

Abstract

Fractures of the distal radius are most commonly caused by hyperextension injuries of the wrist. Tensile forces and force vectors, strength of impact, bone strength and soft tissue tension create individually different fracture patterns. Metaphyseal comminution, loss of cortical support, ligament avulsion and shear fragments are defining parameters for fracture instability. The dislocation of the articular fragment follows the force vectors of the extrinsic forearm muscles bridging the joint. The goal-plan-standardized (GPS) treatment strategy has proven to be helpful in choosing the ideal individual treatment. It is based on individual patient demands on wrist function and an analysis of fracture instability in computed tomography (CT) scans. The “goal” is a realistic expectation assessed by patient and surgeon. The “plan” includes a benefit-risk analysis and selection of an appropriate treatment modality. The “standardized treatment” of surgical and follow-up treatment is based on biomechanical knowledge. Locking plate osteosynthesis aims to neutralize dislocating force vectors and to allow early active mobility. Unidirectional instability can be indirectly neutralized by palmar locking plate systems. A multidirectional instability can be addressed by multiple plating following the column theory. Distal shear and avulsion fractures may require a fragment-specific osteosynthesis approach.

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  1. Univ.-Klinik für Unfallchirurgie, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich

    M. Gabl, R. Arora &  G. Schmidle

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  1. M. Gabl
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  2. R. Arora
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Correspondence to G. Schmidle.

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M. Gabl, R. Arora und G. Schmidle geben an, dass kein Interessenkonflikt besteht.

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Gabl, M., Arora, R. & Schmidle, G. Biomechanik distaler Radiusfrakturen. Unfallchirurg 119, 715–722 (2016). https://doi.org/10.1007/s00113-016-0219-8

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