今日の臨床サポート

橈骨遠位端骨折

著者: 長田伝重 獨協医科大学 日光医療センター整形外科

監修: 落合直之 キッコーマン総合病院外科系センター

著者校正/監修レビュー済:2021/10/20
参考ガイドライン:
  1. 日本整形外科学会日本手外科学会:橈骨遠位端診療ガイドライン2017 改訂第2版 南江堂 2017年
患者向け説明資料

概要・推奨   

  1. 転位のある橈骨遠位端骨折は、なんらかの麻酔下に徒手整復を行うことが推奨される(推奨度1
  1. 徒手整復後ギプスシーネ固定後のpalmar tiltが-10°未満でulnar varianceが2mm以下(健側差)であれば保存的加療推奨される(推奨度1
  1. 不安定型骨折、Smith骨折、掌側Barton骨折、step-offあるいはgapが2mm以上ある関節内骨折、Melone分類III、IV型、両側骨折例、開放性骨折は手術療法推奨される(推奨度1
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
長田伝重 : 特許使用料(ミズホ株式会社),奨学(奨励)寄付など(ミズホ株式会社)[2021年]
監修:落合直之 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行い、最近話題の掌側月状骨窩骨片の問題について加筆した。

病態・疫学・診察

疾患情報(疫学・病態)  
ポイント:
  1. 橈骨遠位端骨折は、手関節周辺骨折では最も一般的に発生する骨折である。高齢者や小児が手を突いて受傷することが多いが、交通事故、高所からの転落、スポーツなど高エネルギー損傷によっても発生する。ときに尺骨遠位端骨折が合併する。橈骨遠位端骨折の受傷原因は年齢によって異なり、小児ではスポーツ、青壮年男性では転落や交通事故など、骨粗鬆症を伴った40歳以上の女性では転倒が多いが、全体では圧倒的に転倒が多い。
  1. 橈骨遠位端骨折の発生率は脊椎圧迫骨折、大腿骨頚部骨折に次いで多い。
 
解剖の説明:
  1. 前腕遠位部には橈骨と尺骨が存在し、関節は橈骨手根関節と遠位橈尺関節がある。
問診・診察のポイント  
問診:
  1. 受傷原因、受傷時の肢位を確認する(背屈あるいは掌屈強制)。

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文献 

著者: Martin G Mack, Sabine Keim, Jörn O Balzer, Wolfram Schwarz, Kathrin Hochmuth, Joachim Windolf, Thomas J Vogl
雑誌名: Eur Radiol. 2003 Mar;13(3):612-7. doi: 10.1007/s00330-002-1600-2. Epub 2002 Sep 11.
Abstract/Text The purpose of this study was to evaluate the clinical impact of MRI in the early diagnosis of wrist trauma. High-resolution MR imaging was performed on a 1.5-T unit (Symphony Quantum, Siemens, Erlangen, Germany) using coronal and axial T1- and T2-weighted fat-saturated turbo-spin-echo sequence via a dedicated wrist coil within a mean of 6.6 days after initial radiographs in 54 patients (56 wrists) with clinical suspicion of wrist fractures and normal plain or indistinct radiographs. Initial radiographs were evaluated independently by two senior radiologists and the hand surgeon without knowledge of the MRI findings. The initial treatment protocol was based on evaluation of plain films and clinical findings by the hand surgeon. Treatment protocol was changed after MRI examination if necessary. In 31 of 56 wrists MRI findings resulted in a change of diagnosis. There were false-positive diagnoses on plain radiographs in nearly one half ( n=25) of the patients. False-negative diagnoses on plain radiographs resulted in 6 cases. Magnetic resonance imaging detected additional injuries of soft tissue in more than one third ( n=20). In 22 of 56 wrists the period of immobilization could be shortened or ended, in 12 of 56 it was prolonged, and in 3 of 56 a surgical intervention was necessary. In 19 wrists MRI had no therapeutic consequences. Our data demonstrate the high clinical impact of MRI in the detection of acute wrist fractures. We recommend MRI of the wrist immediately on the day of trauma if there is clinical suspicion and normal plain radiographs. Accurate diagnosis by MRI examination within the first days following trauma may reduce economic costs due to shortened immobilization time in cases with a suspected fracture but plain radiographs.

PMID 12594566  Eur Radiol. 2003 Mar;13(3):612-7. doi: 10.1007/s00330-0・・・
著者: J L Orbay
雑誌名: Hand Surg. 2000 Dec;5(2):103-12.
Abstract/Text Stable internal fixation and early motion has not been routinely available for distal radius fractures. Difficulties with the dorsal approach discourage surgeons from internally fixing the most common fracture types. The introduction of a new volar plate with subchondral support fixation allows the treatment of most distal radius fractures with stable internal fixation and early motion while avoiding the complications inherent in the dorsal approach.

PMID 11301503  Hand Surg. 2000 Dec;5(2):103-12.
著者: Denju Osada, Shuzo Kamei, Koichiro Masuzaki, Morimitsu Takai, Masahiro Kameda, Kazuya Tamai
雑誌名: J Hand Surg Am. 2008 May-Jun;33(5):691-700. doi: 10.1016/j.jhsa.2008.01.024.
Abstract/Text PURPOSE: To prospectively determine the results of treatment of distal radius fractures with a volar locking plate system with no bone graft and early mobilization.
METHODS: Internal fixation and early mobilization of dorsally displaced, unstable fractures of the distal radius using a volar locking plate system without bone grafting was investigated in a prospective series of 49 fractures in 49 consecutive patients. All patients were allowed to move the wrist joint immediately after surgery. Physical examination at 5 weeks, 3 months, 6 months, and 1 year after the operation were performed. Radiographic parameters on preoperative, postoperative, and 1-year postoperative radiographs were compared. At 1-year review, the final clinical functions were evaluated with the Gartland and Werley functional scoring system, a modified Green and O'Brien system, and the Disabilities of the Arm, Shoulder, and Hand questionnaire.
RESULTS: The average radiographic results at 1 year were 9 degrees of volar tilt; 22 degrees of radial inclination; 1 mm of ulnar variance, and 0 mm of articular incongruity. At 1-year review, an excellent or good result was found according to the system of Gartland and Werley and a modified Green and O'Brien system with scores of 100% and 98%, respectively. The Disabilities of the Arm, Shoulder, and Hand score averaged 6, indicating a high degree of patient satisfaction. There were no cases of infection, complex regional pain syndrome, tendon rupture, tendon irritation, nerve injury, or implant failure.
CONCLUSIONS: The volar locking plate fixation without bone grafting and early mobilization is a safe and effective treatment for dorsally displaced, unstable fractures of the distal radius.

PMID 18590852  J Hand Surg Am. 2008 May-Jun;33(5):691-700. doi: 10.101・・・
著者: Masao Nishiwaki, Kenichi Tazaki, Hidenori Shimizu, Asif M Ilyas
雑誌名: J Bone Joint Surg Am. 2011 Aug 3;93(15):1436-41. doi: 10.2106/JBJS.J.01159.
Abstract/Text BACKGROUND: Intramedullary nailing for the treatment of unstable distal radial fractures is reported to provide stable fixation with minimal soft-tissue complications, but there is a paucity of data documenting the results of this technique. The purpose of this study was to prospectively determine the functional outcomes of treatment of unstable distal radial fractures with an intramedullary nail.
METHODS: Patients aged fifty years and older with a dorsally displaced unstable distal radial fracture--an extra-articular or simple intra-articular fracture--that was amenable to closed or percutaneous reduction were offered treatment with intramedullary nail fixation (MICRONAIL). Thirty-one patients were enrolled in the study, and twenty-nine patients with a mean age of sixty-seven years (range, fifty-one to eighty-five years) were available for one-year follow-up. According to the AO classification, there was one type-A2, twenty-four type-A3, and four type-C2 distal radial fractures. The patients were evaluated at six weeks, three months, six months, and one year after surgery. Outcome measures included standard radiographic parameters, active wrist range of motion, grip strength, a modified Mayo wrist score, and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.
RESULTS: At the final one-year follow-up evaluation, the active range of motion of the injured wrist relative to that on the uninjured side averaged 95% of flexion, 95% of extension, 93% of ulnar deviation, 91% of radial deviation, 99% of pronation, and 99% of supination. The mean grip strength was 96% of that on the uninjured side. According to the modified Mayo wrist score, there were twenty excellent and nine good results. The mean DASH score was 4.8 points. The final radiographic measurements demonstrated, on average, 25° of radial inclination, 11° of volar tilt, 10 mm of radial length, and +1 mm of ulnar variance. Loss of reduction occurred in two patients. One patient developed transient superficial radial sensory neuritis, which resolved within two months.
CONCLUSIONS: Intramedullary nailing can be a safe and effective treatment with minimal complications for dorsally displaced unstable extra-articular or simple intra-articular distal radial fractures.

PMID 21915549  J Bone Joint Surg Am. 2011 Aug 3;93(15):1436-41. doi: 1・・・
著者: John D Beck, Neil G Harness, Hillard T Spencer
雑誌名: J Hand Surg Am. 2014 Apr;39(4):670-8. doi: 10.1016/j.jhsa.2014.01.006. Epub 2014 Mar 6.
Abstract/Text PURPOSE: To determine the percentage of AO B3 distal radius fractures that lose reduction after operative fixation and to see whether fracture morphology, patient factors, or fixation methods predict failure. We hypothesized that initial fracture displacement, amount of lunate facet available for fixation, plate position, and screw fixation would be significant risk factors for loss of reduction.
METHODS: A prospective, observational review was conducted of 51 patients (52 fractures) with AO B3 (volar shearing) distal radius fractures treated operatively between January 2007 and June 2012. We reviewed a prospective distal radius registry to determine demographic data, medical comorbidities, and physical examination findings. Radiographs were evaluated for AO classification, loss of reduction, length of volar cortex available for fixation, and adequacy of stabilization of the lunate facet fragment with a volar plate. Preoperative data were compared between patients who maintained radiographic alignment and those with loss of reduction. A multivariate logistic regression analysis was completed to determine significant predictors of loss of reduction.
RESULTS: Volar shearing fractures with separate scaphoid and lunate facet fragments (AO B3.3), preoperative lunate subsidence distance, and length of volar cortex available for fixation were significant predictors for loss of reduction; the latter was significant in multivariate analysis. Plate position and number of screws used to stabilize the lunate facet were not statistically different between groups.
CONCLUSIONS: Patients with AO B3.3 fractures with less than 15 mm of lunate facet available for fixation, or greater than 5 mm of initial lunate subsidence, are at risk for failure even if a volar plate is properly placed. In these cases, we recommend additional fixation to maintain reduction of the small volar lunate facet fracture fragments in the form of plate extensions, pins, wires, suture, wire forms, or mini screws.
TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
PMID 24613588  J Hand Surg Am. 2014 Apr;39(4):670-8. doi: 10.1016/j.jh・・・
著者: Yoshiro Kiyoshige
雑誌名: Tech Hand Up Extrem Surg. 2002 Dec;6(4):205-8.
Abstract/Text The author established a new reduction and fixation technique for osteoporotic distal radius fracture with a use of AO/ASIF volar distal radius plate, referring to the condylar plating technique in distal femoral fracture. This technique is performed in three steps. First, distal fixation is through the insertion of buttress pins just beneath the subchondral bone with a convergent angle of 10 degrees to the articular surface under fluoroscopic assistance. Second, the proximal limb of the plate is lined up with the radius shaft so that the fracture is reduced automatically and anatomically. Third, by rotating the proximal limb of the plate ulnarly and lifting up the ulnar border of the articular surface, the fracture is fixed less than the contralateral ulnar variance, to apply an adequate tension on the triangular fibrocartilage complex (TFCC). This method represents a valuable treatment modality for the most frequent types of unstable distal radius in elderly women.

PMID 16520603  Tech Hand Up Extrem Surg. 2002 Dec;6(4):205-8.
著者: Neil G Harness, Jesse B Jupiter, Jorge L Orbay, Keith B Raskin, Diego L Fernandez
雑誌名: J Bone Joint Surg Am. 2004 Sep;86(9):1900-8. doi: 10.2106/00004623-200409000-00007.
Abstract/Text BACKGROUND: The purpose of the present study is to report on a cohort of patients with a volar shearing fracture of the distal end of the radius in whom the unique anatomy of the distal cortical rim of the radius led to failure of support of a volar ulnar lunate facet fracture fragment.
METHODS: Seven patients with a volar shearing fracture of the distal part of the radius who lost fixation of a volar lunate facet fragment with subsequent carpal displacement after open reduction and internal fixation were evaluated at an average of twenty-four months after surgery. One fracture was classified as B3.2 and six were classified as B3.3 according to the AO comprehensive classification system. All seven fractures initially were deemed to have an adequate reduction and internal fixation. Four patients required repeat open reduction and internal fixation, and one underwent a radiocarpal arthrodesis. At the time of the final follow-up, all patients were assessed with regard to their self-reported level of functioning and with use of Sarmiento's modification of the system of Gartland and Werley.
RESULTS: At a mean of two years after the injury, six patients had returned to their previous level of function. The result was considered to be excellent for one patient, good for four, and fair for two. The average wrist extension was 48 degrees, or 75% of that of the uninjured extremity. The average wrist flexion was 37 degrees, or 64% of that of the uninjured extremity. The one patient who underwent radiocarpal arthrodesis had achievement of a solid union. The four patients who underwent repeat internal fixation had maintenance of reduction of the lunate facet fragment. The two patients who declined additional operative intervention had persistent dislocation of the carpus with the volar lunate facet fragment.
CONCLUSIONS: The stability of comminuted fractures of the distal part of the radius with volar fragmentation is determined not only by the reduction of the major fragments but also by the reduction of the small volar lunate fragment. The unique anatomy of this region may prevent standard fixation devices for distal radial fractures from supporting the entire volar surface effectively. It is preferable to recognize the complexity of the injury prior to the initial surgical intervention and to plan accordingly.

PMID 15342751  J Bone Joint Surg Am. 2004 Sep;86(9):1900-8. doi: 10.21・・・

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