臺灣博碩士論文加值系統

研究背景與目的：先前研究已指出遠端橈骨骨折(distal radius fracture, DRF)的後遺症包含未受傷關節的僵硬(stiffness)與攣縮(contracture)，其中又以手指關節最為容易產生傷後僵硬之情形，然而實際在介入DRF個案時，儘管術後衛教計畫中包含活動手指的項目，但是目前臨床實證上卻很少研究去探討病患實際執行衛教活動之情形、手指在腕關節術後固定下的關節活動度變化之情形，以及個案接受早期手指活動介入之相關功能性成效等資料。就臨床觀察及經驗所得，不難發現DRF個案的手指關節在腕部復原過程中及復原後仍有僵硬的情形發生，進而影響到他們手指的功能性或日常生活、工作之表現。故本研究目的為：欲在術後即進行早期介入，特別加強易僵硬的手指關節的活動及減少術後水腫的產生，利用客觀的生物力學研究探討進行早期介入的個案，是否在拆掉腕部外固定器之後有較少手指關節僵硬的情形與有較好的手部功能性表現結果。
研究方法： 本研究共收集22位DRF個案，其中11人為早期介入組，另外11人為對照組。早期介入組將於術後第一天即進行早期手指活動治療方案與居家運動治療方案約6-8週，俟腕部固定器移除後，繼續接受手腕部之復健活動，總治療療程共計12週；對照組則於移去固定後使接受手腕部之復健活動之介入，直至術後第12週。評估內容則包含檢驗水腫情形、疼痛、手指肌力與握力、手指與手腕關節活動度與最大活動空間、手部功能性表現、生活品質、治療順應性以及骨頭本身的情形等。分別於術後第1週、術後第3週、移除固定後第1週、術後第12週進行評估，一共評估4次。當數據皆收集完成後，將以描述性統計的方法分析人口學資料、骨折嚴重程度以及運動學參數。並使用Mann-Whitney U test檢定各組間參數是否具有顯著性差異以及使用效果值(effect size)檢驗介入效果。
結果：本研究受試者早期介入組為59.27 ± 5.26歲，控制組為64.91 ± 7.57歲，基本人口學資料、骨折嚴重度、骨折癒合因子等在兩組之間皆無統計上之顯著差異。只有在拆除外固定器後的第一個星期評估時(第三次評估)兩組個案之中指近、遠端之指圍達統計上顯著性差異(p= .033、p= .011)，效果值(Effect Size)在第二次評估與第三評估時也有小至強的介入效果存在(Effect Size=0.30~0.92)。早期介入組的手指活動面積比與其改善皆較控制組佳，其效果值在每次評估時為小至中(Effect Size=0.28~0.74)，而在每段時期的改善量中也有中至強的效果值存在(Effect Size=0.51~0.81)。手指靈活度只有在拆除外固定器後至結案這段時期中的改善的情形有統計上顯著差異(p= .038, Effect Size=0.40)，但早期介入組在早期手指活動介入期間患側手置放的改善情形大於控制組，有強的效果值(Effect Size=0.89)。剛拆除固定器後(第三次評估)時早期介入組的肌力表現皆較控制組佳，側邊捏力與三點捏力有統計學上顯著差異(p=.039 ＆ .045)，握力有中度效果值(Effect Size=0.63)。在第四次評估時，早期介入組在側邊捏力與握力方面平均仍較控制組佳，有中度效果值(Effect Size=0.50 ＆ 0.77)。疼痛早期介入組在每次評估時皆較控制組平均疼痛分數低，效果值為中至強(Effect Size=0.64~0.92)。
討論：從結果得知，早期手指活動介入不會影響骨折癒合，且接受早期手指活動介入的病患水腫與疼痛降低的情形較佳、手指動作、靈巧度也恢復的較多，生活品質也較控制組佳；但在肌力與手部功能性結果來說，兩組間就較無所差異。整體而言，早期手指活動介入是有所效益的。
結論：早期手指活動介入對於遠端橈骨骨折後的病患功能性的恢復、疼痛的減輕是有助益的，因此建議遠端橈骨骨折後的病患在術後即可開始進行早期手指活動介入，使這些病患在拆除固定後有較佳的功能性結果。

Abstract
Background and purpose: Some clinical evidences have indicated that the uninjured joint stiffness and contracture is one of the complications of patients after distal radius fracture (DRF). The finger joints are reported to have a higher incidence of joint stiffness and contracture than the rates of other joints. Although the finger exercise has been advocated in the discharge plan, few clinical evidences present the realistic practice of the execution of the finger exercise of the patients, the change of range of motion (ROM) of fingers over a period of time after the external fixation of the wrist joint, and the effect of early finger intervention on the finger mobility and functional performance. From our clinical observations, it is not difficult to discover that joint stiffness or contracture is easily detected during fractural healing, even after completely bony recovery, so that the functional outcomes of the hand are usually not satisfied owing to the limitation of joint mobility. Hence, the purpose of this study is to investigate the effect of early intervention, which consists of finger joint mobilization and edema control, on the functional outcome performances of patients after receiving external fixation of DRF based on objective biomechanical and clinical assessments.
Methods: This study recruited 22 patients suffering from DRF and receiving wrist external fixation surgically. 11of them were randomly assigned to the early intervention group and the other 11 were allocated to the controlled group. Patients in the early intervention group received early finger intervention and designated home program immediately after surgically external fixation until 12 weeks after surgery. The controlled group only received hand rehabilitation after removing the external fixation (around 6-8 weeks) until 12 weeks after surgery. The assessments for the outcome measures include the evaluations of edema (measuring tape), pain (10 points VAS), strength (lateral pinch, three-jaw pinch, and grip power, measured by JAMAR? Hydraulic Pinch Gauge and JAMAR? Grip Hand Dynamometer respectively), ROM and maximal working space of finger and thumb (miniBird (a electromagnetic field motion monitor), Innovative Sports Training, Inc.), hand functional performance (Manual Ability Measure, MAM), and radiograph in accordance with the following timetable: 1) at the first week and 2) the third week after surgery, 3) at the first week after removing the external fixation, and 4) at the twelfth week after surgery. After data collection, the demography, the level of Frykman classification, and the parameters of kinematics were analyzed by descriptive statistics. The investigation of the measured parameters between these two groups was examined by the Mann-Whitney U test and tested the intervention effect by eddect size.
Results: About the demography, the mean age of the early intervention group and the controlled group were 59.27 ± 5.26 and 64.91 ± 7.57 years old respectively. All subjects were right handed. The level of Frykman classification and radiographic factors had no significant difference between the two groups. The bone healing status which including radial shortening, radial tilt, and volar tilt were no significant difference between the early intervention and controlled groups. There was a significant difference of the distal middle finger at the 3rd assessment (p=.033 ＆ p=.011) between the two groups of edema improving status, and the mean edema improving status in the early intervention group was better than the controlled group.The mean finger motion area in the early intervention group was better than the controlled group . The dexterity improving status had a significant difference (p= .038, Effect Size=0.40) between the two groups. The strength which including lateral pinch, three-jaw pinch, grip power except the grip power, there were significant differences of the three-jaw pinch and later pinch at the 3rd assessment (p=.039 ＆ .045). Finally, the mean pain score of the early intervention group was less than the controlled group.
Discussion: The results demonstrate that the early finger intervention might not be able to affect bone healing status since no significant difference between the intervention and controlled groups. This report also shows that the early finger intervention is effective, because the mean scores of the early intervention group were better than the performances of the controlled group in the edema improving status, pain status, the maximal working space of finger and thumb, strength, and the hand functional performance. The reasons for few significant differences of the above parameters maybe be the number of subjects.
It may recruit more subjects with distal radius fracture by different surgery ways, and attend to compliance of the subjects in the future.
Conclusion: The outcomes of this study provide detailed and objective evidence-based knowledge for further intervention and the hand status progress of the patients with distal radius fracture. Therefore, it might suggest that the orthopedists could refer the patients with distal radius fracture to occupational therapists or hand therapists for early finger mobilization after surgery immediately.

目錄
摘要 i
誌謝 viii
第一章、緒論 1
第一節、研究動機與重要性 1
第二節、研究目的 2
第三節、研究問題與假設 2
第二章、文獻回顧 4
第一節、遠端橈骨骨折簡介 4
第二節、遠端橈骨骨折之復健介入實證 22
第三節、文獻回顧總結 29
第三章、研究方法 31
第一節、研究對象 31
第二節、研究設備及設計 31
第三節、研究流程 44
第四節、數據分析 44
第四章、結果 47
第一節、基本人口學資料 47
第二節、骨折嚴重度及骨折癒合因子 47
第三節、研究問題一 48
第四節、研究問題二 52
第五節、研究問題三 58
第六節、研究問題四 62
第七節、其他結果 63
第五章、討論 68
第一節、骨折嚴重度及骨折癒合因子 68
第二節、研究問題一 68
第三節、研究問題二 69
第四節、研究問題三 71
第五節、研究問題四 72
第六節、其他結果 72
第七節、研究優點、限制與未來方向 73
第六章、結語 76
參考文獻 77
附錄一、基本資料調查表 85
附錄二、自覺徒手功能調查表 86
附錄三、short form 36 87
附錄四、疼痛10分量表 88
附錄五、手指運動確認表 89

表目錄
表一 Frykman classification 7
表二 手腕在腕關節術後固定期間之介入 25
表三 手腕在腕關節術拆除固定器後之介入 28
表四 遠端橈骨骨折後病人至醫院復健部時之早期手指活動介入治療計畫 42
表五 遠端橈骨骨折後病人至醫院復健部時之一般性治療計畫 43
表六 遠端橈骨骨折後病人之家中活動治療方案 43
表七 基本人口學資料 47
表八 骨折嚴重度分類 48
表九 骨頭癒合情形 48
表十 水腫情形 50
表十一-1 手術後至拆除固定器前的時期之水腫改善情形 51
表十二-1 手指活動面積比 53
表十三-1 手指關節活動度比情形 54
表十四-1 拇指活動面積比 55
表十五-1 拇指關節活動度比情形 56
表十六 手腕活動面積比 57
表十七 個案手腕活動面積改善情形 58
表十八 手指靈活度表現結果 58
表十九-1 手術後至拆除固定器前的時期之手部靈巧度改善情形 59
表二十 手部功能表現 60
表二十一-1 手術後至拆除固定器前的時期受測者主觀手部功能性結果改善情形 60
表二十二 肌力比 62
表二十三 疼痛情形 63
表二十四 疼痛改善情形 63
表二十五 生活品質情形 64
表二十六-1 手術後至拆除固定器前的時期之生活品質改善情形 67

圖目錄
圖一 遠端橈骨骨折類型(a) Colles’ fracture；(b) Smith’s fracture (c) volar Barton’s fracture (d) dorsal Barton’s fracture 6
圖二 骨折癒合因子 (a) radial shortening (b) radial tilt (c) volar tilt 15
圖三 測量手部力量之工具 (a) Hydraulic Pinch Gauge (b) Grip Hand Dynamometer 34
圖四 Purdue Pegboard 34
圖五 皮尺 35
圖六 電磁場感應器黏貼位置 (a) 感應器黏貼於手指之位置 (b) 感應器黏貼於拇指之位置 (c) 測量手腕活動空間時感應器黏貼之位置 36
圖七 設置圖與工作站 (a)電磁場設置圖 (b)動作分析系統 37
圖八 研究流程圖 46
圖九 早期介入期間水腫改善程度 52
圖十 手指運動面積比與其改善情形 54
圖十一 拇指運動面積比與其改善情形 57
圖十二 患側手置放改善情形 59
圖十三 疼痛情形 64

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