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研究生： 曾德財
Rudeejaroonrung, Krit
論文名稱： 建構ㄧ有限元素模型探討手腕屈曲/伸展和腕骨排列不正對正中神經壓迫之影響
Finite Element Modeling of the Wrist Flexion/Extension and Carpal Malalignment Effects on Median Nerve Compression
指導教授： 蘇芳慶
Su, Fong-Chin
學位類別： 碩士
Master
系所名稱： 工學院 - 生物醫學工程學系
Department of BioMedical Engineering
論文出版年： 2024
畢業學年度： 112
語文別： 英文
論文頁數： 107
中文關鍵詞： 遠端橈骨骨折癒合列位不良 、腕隧道症候群 、正中神經壓迫 、副木角度
外文關鍵詞： distal radius malunion, carpal tunnel syndrome, median nerve entrapment, splinting angle
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    • 橈骨遠端骨折是成年人中最常見的骨折類型，可能導致橈骨遠端癒合不良，其中以非手術治療約為24%，以手術治療則約占11%。先前的研究表明，患有橈骨遠端癒合不良的患者由於腕骨錯位而患有腕隧道症候群的風險。通常，最常見的治療方法是進行矯正性截骨術，旨在保持原有的腕骨對齊。由於橈骨遠端癒合不良導致軟組織適應，另一種替代方法是非手術治療，通過物理療和副木保護。這些方法可以改善手部功能並緩解症狀，達到無需手術的水平。先前的研究顯示，治療患有腕隧道症候群患者的最佳副木角度是手腕保持正中位置或稍微伸展。然而，由於對正中神經壓力力量變化的了解不足，患有橈骨遠端癒合不良並出現腕隧道症候群的患者的最適當副木角度仍未發現。本研究的目的是利用有限元素模型探討正中神經在不同手腕角度的各種腕骨錯位程度引起的應力和壓力變化。
    從患有橈骨遠端癒合不良的患者中收集了健側與患側的手腕MRI影像，並以健側手腕的MRI影像建構三維模型。模擬條件分為兩個步驟：首先，建立不同程度的腕骨錯位模型，然後對模型進行手腕旋轉以模擬屈曲與伸展60度。錯位嚴重程度的定義為腕骨列往背側移動愈多，且相對於遠端橈骨背側傾斜愈大，代表錯位愈嚴重。本研究探討在不同錯位程度與手腕屈曲伸展時，正中神經的應力分佈，受肌腱壓迫的正中神經的接觸壓力，以及受正中神經壓迫的腕橫韌帶的接觸壓力。此外，本研究亦藉由改變肌腱張力和腕橫韌帶的背側平移進行了敏感性測試。
    結果顯示癒合不良模型在手腕呈輕微伸展角度時正中神經的應力最低。當錯位愈嚴重，其最低應力點所發生的手腕角度會往愈高的伸展角度移動。此項結果指出，用副木將手腕固定在輕微伸展角度可能是患有橈骨遠端癒合不良患者的最佳選擇。此外，更嚴重的癒合不良可能需要更大程度的手腕伸展以達到最低應力點。

    Distal radius fracture (DRF) is the most common type of fracture in adults and could potentially result in distal radius malunion (DRMU), with a prevalence of 24% for non-surgical treatment and 11% for surgical treatment. The previous study shows that patients with DRMU have a risk of developing carpal tunnel syndrome (CTS) due to median nerve entrapment from carpal malalignment. Typically, the most common treatment for DRMU is corrective osteotomy aimed at retaining the original carpal alignment. As DRMU results in soft-tissue adaptation, another alternative way is nonsurgical treatment, which is done through physical therapy and adaptive splinting. These approaches could improve hand function and alleviate symptoms to a level that doesn’t necessitate surgery. The previous study shows that the optimal splinting angle for treating carpal tunnel syndrome in patients is when the wrist remains in a neutral position or experiences slight extension. However, the optimal splinting angle for DRMU patients experiencing carpal tunnel syndrome is still undiscovered due to a lack of knowledge about the pressure force alteration of the median nerve. The purpose of this study is to employ finite element modeling to investigate the stress and compression force changes of the median nerve caused by various levels of carpal malalignment severity at different wrist angles.
    Wrist MRI images were collected from patients with distal radius malunion, capturing both the healthy and injured sides. The three-dimensional model was constructed based on the MRI image of the healthy wrist. The loading conditions were divided into two steps: first, applying different carpal malunion conditions to the model, and second, applying wrist rotation to the model. The increase in carpal malunion severity is defined as an increase in dorsal movement of the carpal row with respect to the dorsal tilt of the distal radius. The stress distribution on the median nerve, the contact pressure of the median nerve affected by the tendon, and the contact pressure of the transverse carpal ligament (TCL) affected by the median nerve are investigated. In addition, the sensitivity tests are done by varying tendon tension and dorsal translation of TCL.
    The malunion model exhibits the lowest stress on the median nerve when the wrist is positioned at a slight extension angle. As the severity of malalignment increases, the point of lowest stress shifts to a higher wrist extension angle. This observation suggests that immobilizing the wrist with a splint at a slight extension angle might be optimal for patients with distal radius malunion. Moreover, higher malunion severity levels may necessitate a greater degree of wrist extension to achieve the lowest stress point.

    Contents 中文摘要 I Abstract III Acknowledgement V Contents VII List of Figure XI List of Table XV CHAPTER 1 INTRODUCTION 1 1.1 Background 1 1.1.1 Distal radius fracture and malunion 1 1.1.2 Carpal malalignment after distal radius malunion 4 1.1.3 Risk of delayed carpal tunnel syndrome after carpal malalignment 10 1.1.4 DRMU Treatment 12 1.1.5 Splinting 13 1.1.6 Wrist biomechanics during wrist flexion and extension movement 14 1.1.7 Finite Element Analysis 17 1.1.8 Finite element analysis in wrist biomechanics 20 1.2 Motivation 21 1.3 Hypothesis and purpose 23 CHAPTER 2 METHODS 24 2.1 Geometry modeling 24 2.2 Carpal alignment and volar tilt correlation 26 2.2.1 Carpal malalignment type 26 2.2.2 Measure radiocapitate distance 27 2.2.3 Generate correlation equation 28 2.3 Material model of tissues 29 2.4 Boundary and contact condition 30 2.5 Design loading condition 32 2.6 Finite Element Sensitivity Study 35 2.6.1 Effect of tendon tension 35 2.6.2 Effect of TCL arch height 35 2.6.3 Effect of TCL stiffness 36 2.7 Finite element processing 36 2.7.1 Maximum Stress on median nerve 38 2.7.2 Maximum contact pressure on median nerve and TCL 39 2.7.3 Stress and pressure distribution 39 2.7.4 Type of analysis 41 2.8 Study scenario 42 CHAPTER 3 RESULTS 46 3.1 Characteristic of carpal alignment from collected MRI image 46 3.1.1 Identify carpal malalignment type with ERLF 46 3.1.2 Volar tilt and RCD correlation 46 3.2 Study of varying carpal malalignment severity 47 3.3 Sensitivity study 56 3.3.1 Tendon tension factor 56 3.3.2 TCL dorsal translation factor 61 3.3.3 TCL stiffness factor 65 3.4 Reaction force 68 CHAPTER 4 DISCUSSION 69 4.1 Effect of carpal malalignment to median nerve and TCL in each wrist posture 69 4.1.1 Wrist at neutral position 70 4.1.2 Wrist flexion 71 4.1.3 Wrist extension 72 4.2 Clinical relevance 73 4.3 Sensitivity study 75 4.3.1 Effect of tendon tension 75 4.3.2 Effect of TCL dorsal movement 76 4.3.3 Effect of TCL stiffness 77 4.4 Reaction force 77 4.5 Validation and Comparison of Results 78 4.5.1 Equivalent stress 78 4.5.2 Contact pressure 79 4.5.3 Hydrostatic pressure 81 4.6 Novelty 82 4.7 Limitations 83 4.8 Future studies 85 4.9 Conclusion 85 REFERENCES 87

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