Iranian Journal of Orthopaedic Surgery Vol 10, No 2 (Serial No 39), Spring 2012:87-92 اﻳﺮان ﻣﻔﺎﺻﻞ و اﺳﺘﺨﻮان ﺟﺮاﺣﻲ ﻣﺠﻠﻪ دوره دﻫﻢ ﺷﻤﺎره، 2 ) ﻣﺴﻠﺴﻞ ﺷﻤﺎره39 ( ، ﺑﻬﺎر1391 ﺻﻔﺤﻪ، ﻫﺎي92 - 87 ﭘﻴﻦ ﭘﻨﺠﻢ ﻛﺎرﭘﻮﻣﺘﺎﻛﺎرﭘﺎل ﻣﻔﺼﻞ ﭘﻮﺳﺘﻲ ﮔﺬاري * د ﻣﻈﻔﺮﻳﺎن ﻛﺎﻣﺮان ﻛﺘﺮ، ** وﺛﻮﻗﻲ اﻣﻴﺮرﺿﺎ دﻛﺘﺮ، *** دﻛﺘﺮ آرﻳﺎ ﺣﺠﺎزي، *** ﻣﺤﻤﺪ دﻛﺘﺮ زارع ﻧﮋاد، *** دﻛﺘﺮﻣﻬﺪي ﺧﺎدم ﻧﻈﻤﻲ » ﭘﺰﺷﻜﻲ ﻋﻠﻮم داﻧﺸﮕﺎه ﺷﻴﺮاز« Journal of Orthopaedic Science. 2012 Nov;17(6):757-62 ﺧﻼﺻﻪ ﭘﻴﺶ زﻣﻴﻨﻪ: درﻣ ﺎن ﺻﺪﻣﺎت ﺑﻲ ﺛﺒﺎت ﭘﻨﺠﻤﻴﻦ ﻣﻔﺼﻞ ﻛﺎرﭘﻮﻣﺘﺎﻛﺎرﭘﺎل دﺳﺖ، ﺟﺎاﻧﺪازي ﺑﺴﺘﻪ و ﭘﻴﻦ ﮔﺬاري ﻣﻲ ﺑﺎﺷﺪ. ﻫﺪف اﻳﻦ ﻣﻄﺎﻟﻌﻪ، ﺗﻌﻴﻴﻦ ﺑﻲ ﺧﻄﺮﻳﻦ ﻣﺴﻴﺮ ﭘﻴﻦ ﮔﺬاري اﻳﻦ ﻣﻔﺼﻞ ﺑﺎ ﺷﻴﻮه اي اﺳﺖ ﻛﻪ از ﺻﺪﻣﺎت اﺣﺘﻤﺎﻟﻲ ﺑﻪ ﻋﺼﺐ اوﻟﻨﺎر و ﺗﺎﻧﺪون ﻫﺎي دﺳﺖ ﺟﻠﻮﮔﻴﺮي ﺷﻮد. ﻣﻮاد و روش ﻫﺎ: ﻣﺮﺣﻠﻪ در اول، ﻣﭻ دﺳﺖ و دﺳﺖ ﺳﻪ ﺟﺴﺪ ﺗﺎزه ﺗﺸﺮﻳﺢ ﺷﺪﻧﺪ و ﺳﭙﺲ ﺑﻲ ﺧﻄﺮﺗﺮﻳﻦ ﻣﺴﻴﺮ ﭘﻴﻦ ﮔﺬاري در ﺳﻄﻮح ﻛﺮوﻧﺎل و ﺳﺎژﻳﺘﺎل ﻧﺴﺒﺖ ﺑﻪ ﻣﺘﺎﻛﺎرﭘﺎل ﭘﻨﺠﻢ دﺳﺖ ﺗﻌﻴﻴﻦ ﮔﺮدﻳﺪ. دوم ﻣﺮﺣﻠﻪ در، ﭘﻴﻦ ﮔﺬاري ﻃﻮري اﻧﺠﺎم ﺷﺪ ﻛﻪ زواﻳﺎي ورودي در ﻫﺮ ﻧﻤﻮﻧﻪ، ﺗﺮﻛﻴﺒﻲ از ﻣﺎﻛﺰﻳﻤﻢ زواﻳﺎي ﺑﺪﺳﺖ آﻣﺪه در ﻣﺮﺣﻠﻪ ﻗﺒﻞ ﺑﺎﺷﺪ. ﺑﻌﺪ از ﭘﺮﺗﻮ ﻧﮕﺎري، ﺷﺪﻧﺪ ﺗﺸﺮﻳﺢ ﻣﭻ و دﺳﺖ. در ﻣﺮﺣﻠﻪ ﺳﻮم، ﭘﻴﻦ ﮔﺬاري در زاوﻳﻪ ﻫﺎي ﺧﺎرج از ﻣﺤﺪوده ﻫﺎي ﻣﺮﺣﻠﻪ اول در دﺳﺖ ﭼﻬﺎر ﺟﺴﺪ اﻧﺠﺎم ﺷﺪ. ﺑﻌﺪ از ﭘﺮﺗﻮﻧﮕﺎري، دﺳﺖ ﻫﺎ ﻛﺎﻟﺒﺪﺷﻜﺎﻓﻲ ﺷﺪﻧﺪ. ﻳﺎﻓﺘﻪ ﻫﺎ: ﺑﻲ ﺧﻄﺮﺗﺮﻳﻦ ﻣﺴﻴﺮ ﺗﻌﻴﻴﻦ ﺷﺪه در اول ﻣﺮﺣﻠﻪ زاوﻳﻪ20 ﺗﺎ30 درﺟﻪ ﺳﻄﺢ ﻛﺮوﻧﺎل ﻧﺴﺒﺖ ﺑﻪ ﻣﺘﺎﻛﺎر ﭘﺎل ﭘﻨﺠﻢ دﺳﺖ و در ﺳﻄﺢ ﺳﺎژﻳﺘﺎل از10 درﺟﻪ وﻻر ﺑﻪ ﺳﻤﺖ دورﺳﺎل ﺗﺎ20 درﺟﻪ دورﺳﺎل ﺑﻪ ﺳﻤﺖ وﻻر ﺑﻮد. در ﻣﺮﺣﻠﻪ دوم ﭘﻴﻦ ﮔﺬاري در ﺗﻤﺎم ﻧﻤﻮﻧﻪ ﻫﺎ ﺑﺎ ﻋﺒﻮر ﭘﻴﻦ از وﺳﻂ ﻣﻔﺼﻞ ﺑﺎﻋﺚ ﺗﺜﺒﺖ ﻣﺤﻜﻢ ﻣﻔﺼﻞ ﺷﺪ. ﺗﻤﺎم ﭘﻴﻦ ﻫﺎي ﮔﺬاﺷﺘﻪ ﺷﺪه در ﻣﺮﺣﻠﻪ ﺳﻮم ﺑﺎﻋﺚ ﺻﺪﻣ ﻪ ﺑﻪ ﻋﺼﺐ اوﻟﻨﺎر ﻳﺎ ﺗﺎﻧﺪون ﻫﺎ ي دﺳﺖ ﺷﺪﻧﺪ ﺑﺎ و ﻛﻨﺎره از ﻋﺒﻮر ﺑﺎ ﻣﻔﺼﻞ، ﻫﺎي ﻧﺘﻮاﻧﺴﺘﻨﺪ ﺗﺜﺒﻴﺖ ﻣﺤﻜﻢ اﻳﺠﺎد ﻛﻨﻨﺪ. ﻧﺘﻴﺠﻪ ﮔﻴﺮي: ﺑﻲ ﺧﻄﺮﺗﺮﻳﻦ راﻫﺮو ﺑﺮاي ﭘﻴﻦ ﮔﺬاري در ﺻﺪﻣﺎت ﺑﻲ ﺛﺒﺎت ﻣﻔﺼﻞ ﭘﻨﺠﻢ ﻛﺎرﭘﻮﻣﺘﺎﻛﺎرﭘﺎل دﺳﺖ ﺑﺎ ﻣﺤﻞ ورود2 ﺳﺎﻧﺘﻲ ﻣﺘﺮي دﻳﺴﺘﺎل از ﺳﻄﺢ ﻣﻔﺼﻞ،20 ﺗﺎ30 درﺟﻪ در ﺳﻄﺢ ﻛﺮوﻧﺎل و از10 درﺟﻪ وﻻر ﺑﻪ دورﺳﺎل ﺗﺎ20 درﺟﻪ دورﺳﺎل ﺑﻪ وﻻر در ﺳﻄﺢ ﺳﺎژﻳﺘﺎل ﻣﻲ ﺑﺎﺷﺪ. واژه ﻛﻠﻴﺪي ﻫﺎي: اﺳﻜﻠﺘﻲ، ﺗﺜﺒﻴﺖ ﻛﺎرﭘﻮﻣﺘﺎﻛﺎرﭘﺎل، ﻣﻔﺼﻞ ﺳﻴﻢ ﻛﺮﺷﻨﺮ ﻣﻘﺎﻟﻪ درﻳﺎﻓﺖ: 2 ؛ ﭼﺎپ از ﻗﺒﻞ ﻣﺎه ﺑﺎزﻧﮕﺮي و اﺻﻼح ﻣﺮاﺣﻞ: 1 ؛ ﺑﺎر ﻣﻘﺎﻟﻪ ﭘﺬﻳﺮش: 1 ﻣﺎه ﭼﺎپ از ﻗﺒﻞ Percutaneous Pinning of the Fifth Carpometacarpal Joint * Kamran Mozaffarian, MD; ** Amir Reza Vosoughi, MD; *** Arya Hedjazi, MD; *** Mohammad Zarenezhad, MD; *** Mehdi Khadem Nazmi, MD Abstract Background: Traditional treatment of unstable fifth carpometacarpal joint injuries is closed reduction and pinning. The aim of this study was to determine the safest corridor for pinning of fifth carpometacarpal joint to prevent the iatrogenic injury to the ulnar nerve and tendons . Methods: In the first phase of study, three fresh cadaver samples were dissected and the safest directions of kirschner wire insertion in coronal and sagittal planes were determined to the base of the fifth metacarpal. The second phase evaluated the accuracy of data obtained in previous phase. Therefore k-wires were inserted in combination of maximum angles in different planes determined previously. After taking X-rays, the ulnar nerve branches and tendons were explored to detect any possible damage. In the third phase, four fresh carpometacarpal joints were fixed with directions outside the range of defined angles. Results: The safe direction determined in the first phase was 20° to 30° coronal plane angle in regard to body of the fifth metacarpal bone and between 10° volar to dorsal to 20° dorsal to volar angle in sagittal plane. Insertion of k-wires in the second phase could fix the fifth carpometacarpal joint firmly. All inserted k-wires outside the defined range resulted in injuries to nerve or tendons or infirm fixation Conclusions: The safest corridor for pinning the unstable fifth carpometacarpal injuries is two centimeters distal to the joint with 20° to 30° in coronal plane and from 10° volar to dorsal to 20° dorsal to volar direction in sagittal plane. Key words: Carpometacarpal joints; Skeletal fixation; Kirschner wires Received: 2 months before printing ; Accepted: 1 month before printing *Orthopaedic Surgeon, Department of Orthopaedics, Shiraz University of Medical Sciences, Shiraz, IRAN. **Resident of Orthopaedic Surgery, Department of Orthopaedics, Shiraz University of Medical Sciences, Shiraz, IRAN. ***General Physician, Fars Province-General Office of Legal Medicine, Shiraz, IRAN. Corresponding author: Amir Reza Vosoughi, MD Chamran Hospital, Bone and Joint Disease Research Center, Shiraz University of Medical Sciences, Shiraz, Iran e-mail: vosoughiar@hotmail.com The article is the First Prize winning entry in the 20 th Congress of Iranian Orthopaedic Association,October 2012. The article has published in the J Orthop Sci. 2012 Nov;17(6):757-62. ﭘﮋوﻫﺸﻲ ﻣﻘﺎﻟﻪ