距骨骨折的手术治疗

目的:探讨距骨骨折的特点、类型、手术方法及影响疗效的相关因素。方法:本组距骨骨折39例,其中男29例,女10例;年龄23~55岁,平均32.5岁。骨折根据Hawkins分型方法:Ⅰ型骨折5例,Ⅱ型骨折25例,Ⅲ型骨折9例。Ⅰ型骨折采用松质骨拉力螺钉内固定。Ⅱ、Ⅲ型骨折行急诊手术,其中Ⅱ型骨折采用前外侧切口暴露,解剖复位,2枚松质骨拉力螺钉交叉内固定;Ⅲ型骨折采用踝前内侧切口暴露,解剖复位,松质骨拉力螺钉内固定,伴有内踝骨折时同时复位内固定,并以自体髂骨块跨骨折线嵌入植骨。术后短腿石膏管形外固定12~24周,X线片示骨折线模糊后拆石膏行不负重下踝关节活动,骨折线消失后恢复伤前活动。结果:除2例失访外,37例获得随访。随访时间1.5~6年,平均3年。根据Hawkins疗效标准评定:优12例(32.4%),良17例(45.9%),可6例(16.2%),差2例(5.4%),优良率为78.4%。结论:距骨骨折通过急诊手术、解剖复位、有效内固定、自体髂骨块嵌入植骨、局部封闭、理疗等综合治疗,可降低病残率。     

距骨骨折脱位的手术治疗

目的探讨距骨骨折脱位的特点、类型、手术方法及影响疗效的相关因素。方法本组距骨骨折脱位30例,均为男性;年龄18~46岁,平均33.6岁。骨折根据Hawkins分型,Ⅰ型4例,Ⅱ型20例,Ⅲ型6例。Ⅰ型距骨骨折采用闭合松质骨拉力螺钉内固定。Ⅱ、Ⅲ型骨折均行急诊手术,采用前外侧或前内侧切口暴露,骨折解剖复位后,以2枚松质骨拉力螺钉交叉内固定;其中Ⅲ型骨折并取自体髂骨块跨骨折线嵌入植骨。术后踝关节中立位短腿石膏管形外固定8~12周,复查X线示骨折线模糊后拆除石膏行不负重下踝关节活动,骨折线消失后可完全负重行日常活动。结果 30例均获得随访,随访时间1.5~6年,平均3年。根据美国足踝协会后足评分系统评定,优10例(33.3%),良13例(43.3%),可5例(16.7%),差2例(6.7%),优良率为76.6%。结论距骨骨折脱位虽然并发症多并且后果严重,但是通过急诊手术、骨折解剖复位、尽量保护血运、有效内固定、自体髂骨块跨骨折线嵌入植骨、术后力争早期踝关节功能锻炼,可降低病残率。     

距骨骨折的治疗

目的:探讨距骨骨折的特点、分型、治疗方法及并发症防治。方法:1995年6月～2004年12月共治疗距骨骨折患者52例。根据Hawkins分型方法,Ⅰ型骨折8例,Ⅱ型骨折32例,Ⅲ型骨折10例。另有2例为距骨体骨折。Ⅰ型骨折行保守治疗;Ⅱ、Ⅲ、型骨折中,开放性骨折或伴有脱位的闭合骨折行急诊手术,解剖复位,松质骨拉力螺钉内固定;Ⅲ型骨折同时行距下关节一期融合。术后短腿石膏托或保护支具固定8～12周,并术后早期予CPM(持续被动活动)。至X线片示骨折愈合后逐渐负重。结果:46例获得随访,随访时间4月～5年,平均3.2年。按Howkins疗效标准:优14例(30.4%),良26例(56.5%),可4例(8.7%),差2例(4.3%);优良率为86.9%。术后发生距骨体坏死6例Ⅱ型骨折2例(发生坏死后行关节融合术),Ⅲ型骨折4例。另外,发生距骨下关节炎5例,其中3例合并踝关节炎。发生踝部皮肤坏死2例,伤口感染5例。结论:距骨骨折系高能创伤的结果,并发症多且后果严重,宜早期进行有效解剖复位和固定;术中应首先解决关节脱位,再进行骨折的复位和内固定。手术应力求简单,减少对局部软组织和血运的破坏和干扰,从而减少并发症的发生。术后进行早期功能康复有利用于功能的改善。     

闭合复位空心拉力螺钉内固定治疗距骨颈骨折

目的评价采用闭合复位辅助空心拉力螺钉内固定治疗距骨颈骨折的可行性和疗效。方法对2002年9月至2005年9月收治并获得随访的19例距骨颈骨折进行回顾性分析。所有骨折均按Hawkins分型:Ⅰ型6例,Ⅱ型10例,Ⅲ型3例,全部采用闭合复位辅助空心拉力螺钉内固定方法治疗,术后复查随访,条件允许时去除石膏外固定,进行功能锻炼。结果随访1～3年,平均19.6个月,采用Hawkins评分:优5例(Ⅰ型2例、Ⅱ型3例),良7例(Ⅰ型4例、Ⅱ型3例),中3例(Ⅱ型2例、Ⅲ型1例),差4例(Ⅱ型2例、Ⅲ型2例),优良率为63.2%。合并内翻畸形2例,距骨缺血性坏死3例,踝及距下关节创伤性关节炎4例,骨折延迟愈合1例,4例术后1年行关节融合术。结论闭合复位辅助空心拉力螺钉内固定是一种有效的适宜于距骨颈骨折的治疗方法。既能实现骨折复位和稳固固定的作用,又避免了切开复位和内固定对骨折周围血供的进一步破坏,可降低距骨的缺血性坏死的发生。     

微小切口空心拉力螺钉内固定治疗距骨颈骨折的疗效分析

目的总结微小切口空心拉力螺钉内固定治疗距骨颈骨折的临床疗效。方法回顾性分析2008年1月~2013年11月我院诊治的28例距骨颈骨折患者临床资料。骨折按Hawkins分型:Ⅰ型2例,Ⅱ型22例,Ⅲ型3例,Ⅳ型1例。均在C臂X线机透视下行急诊闭合复位(7例)或开放微小切口切开复位(21例),空心拉力螺钉内固定治疗,术后定期复查、随访。结果本组患者手术时间平均60(50~80)min,术中出血约30 ml,无一例发生伤口感染、皮肤软组织坏死等围手术期并发症。28例患者均获随访,平均18(6~36)个月。本组骨折愈合时间10~14个月,平均(12.0±0.5)月。根据Hawkins标准评估疗效:优23例,良4例,差1例,优良率为96.4%。1例HawkinⅣ型患者发生距骨体明显硬化坏死。结论微小切口空心拉力螺钉内固定是有效治疗距骨颈骨折的方法之一,可以明显减少距骨缺血性坏死并发症的发生。     

距骨颈骨折的手术治疗

目的：探讨手术复位螺钉内固定治疗距骨颈骨折的临床效果。方法：28例距骨颈骨折患者,男20例,女8例;年龄22～72岁,平均38岁。所有骨折按Hawkins法分型,Ⅰ型6例,Ⅱ型18例,Ⅲ型4例。均行切开复位螺钉内固定,其中6例行急诊手术。结果：28例均获随访,时间1～7年,平均2.8年。按Hawkins疗效标准：优14例,良9例,可3例,差2例,优良率为83.2%。术后出现距骨体坏死5例,Ⅱ型骨折3例,Ⅲ型骨折2例,其中2例因距骨体坏死、塌陷或疼痛性关节炎而行踝关节融合术;术后出现单纯踝关节炎3例;距骨下关节炎6例,其中2例合并踝关节炎;无伤口感染和踝关节内侧皮肤坏死。结论：手术复位螺钉内固定治疗距骨颈骨折可取得满意的临床疗效,保护残存血运,解剖复位,稳定内固定可提高治疗效果。     

应用微型钢板和螺钉内固定治疗距骨骨折22例

目的：探讨微型钢板和螺钉内固定治疗距骨体和距骨颈骨折的效果。方法：经前内外侧联合入路,采用传统拉力螺钉辅助距骨外侧微型钢板内固定,必要时行距骨颈内侧植骨治疗距骨颈骨折15例,采用螺钉治疗距骨体骨折7例,术后采用Hawkins评分和放射学检查,分析其临床疗效和并发症。结果：22例中术后发生创伤性关节炎11例,距骨体坏死4例;Hawkins评分,优7例,良9例,可4例,差2例。结论：传统拉力螺钉辅助距骨外侧微型钢板内固定治疗距骨颈骨折,可减少距骨颈骨折内翻畸形发生,可以减少骨折后期复位丢失,并发症少,值得临床推广应用。     

Acutrak钉治疗距骨颈骨折

目的 探讨利用Acutrak钉固定结合不同植骨方式治疗距骨颈骨折的疗效.方法 2006年10月至2010年5月应用Acutrak钉内固定治疗22例距骨颈骨折患者,男14例,女8例;年龄17～48岁,平均33.5岁.其中Hawkins Ⅰ型骨折(4例)采用经皮内固定;Ⅱ型(11例)采用前内侧切口内固定加植自体髂骨;Ⅲ型(7例)采用带血管蒂的腓骨瓣逆行转移加固定术.Ⅱ、Ⅲ型骨折术后石膏固定骨折至愈合后负重.结果 患者术后获2～4年(平均2.8年)随访.术后伤口均一期愈合,距骨骨折均获愈合,无距骨坏死等并发症发生.按Hawkins评分标准评定疗效:优9例,良7例,可4例,差2例,优良率为72.7%.其中踝关节创伤性关节炎2例,距下关节创伤性关节炎3例.结论 Acutrak钉渐进式加压螺钉可使骨折固定更加坚固,效果优于空心钉及可吸收钉.采用闭合经皮固定、自体髂骨植骨、带血管蒂的腓骨瓣逆行转移针等方法对不同骨折类型均具有优越性,根据不同的骨折类型选择不同的手术方法可获得较好疗效.     

闭合复位空心拉力螺钉内固定治疗距骨颈骨折

目的 评价采用闭合复位空心拉力螺钉内固定治疗距骨颈骨折的可行性和疗效.方法 收治19例距骨颈骨折.所有骨折全部采用闭合复位辅助空心拉力螺钉内固定治疗.结果 随访1～3年,疗效评定采用Hawkins评分:优5例,良7例,中3例,差4例,优良率为63.2%.结论 闭合复位空心拉力螺钉内固定是一种治疗距骨颈骨折的有效方法 ,既能实现骨折复位和稳固固定的作用,又避免了切开复位内固定对骨折周围血供的进一步破坏,可降低距骨缺血性坏死的发生.     

距骨颈骨折的手术治疗

目的探讨距骨颈骨折的特点、分型手术方法及并发症防治。方法1996年7月～2001年11月，共治疗距骨颈骨折患者47例．男32例．女15例；年龄18～49岁，平均31．6岁；坠落伤13例，车祸伤28例．其它损伤6例；合并踝部骨折12例；开放性骨折脱位4例。根据Hawkins分型方法，Ⅰ型骨折6例，Ⅱ型骨折26例．Ⅲ型骨折15例。Ⅰ型骨折为无移位、稳定性骨折，采取非负重石膏管型固定；Ⅱ、Ⅲ型骨折行急诊手术，解剖复位．松质骨拉力螺钉内固定，其中Ⅲ型骨折同时行距下关节一期融合．非负重短腿石膏管型固定8～48周，至X线片示骨折愈合后，再逐渐负重。结果生部病例均获得随访，隧访时间2～5年．平均3.6年。根据患者的主诉、后跟及踝关节的外形、功能及X线征象来分析临床疗效，优17例(362％)，良22例(46．8％)．可5例(10．6％)，差3例(6．4％)；优良率为83．0％。术后发生距骨体坏死8例，Ⅱ型骨折3例；Ⅲ型骨折5例，其中术后3例因距骨体坏死、塌陷或疼痛性关节炎而行踝关节融合术。单纯踝关节炎4例；距骨下关节炎61例，其中3例台并踝美节炎；踝关节内侧皮肤坏死、缺损1例。结论距骨颈骨折并发症多而后果严重，宜早期诊断并进行有效解剖复位和固定，以预防距骨体缺血性骨坏死、创伤性关节炎、骨折愈台不良等并发症，     

Management of hip fractures in the elderly

A fracture of the proximal femur (or hip fracture) is a devastating injury to an elderly patient. Nearly all patients require surgery as part of their treatment but their care necessitates complex multidisciplinary involvement. In the last few years there have been a number of initiatives to help improve care for this challenging patient group, as well as establishment of National Hip Fracture Databases, to allow us to audit the care provided. With this focus we have seen both mortality and length of stay decrease. The aim of this article is to summarize the current recommendations for patients who suffer a hip fracture.     

Research Update on Stress Riser Fractures

Stress fractures are fatigue-induced fractures which are caused by repetitive force, often from overuse. They are well-established and frequently encountered in the field of orthopedics. Stress fractures occur in the bone because of low-bone strength and high chronic mechanical stress placed on the bone. Stress riser fractures are also stress fractures that occur because of the presence of cortical defects (holes), changes in stiffness, sharp corners, and cracks (fracture lines). Periprosthetic or peri-implant fractures are good examples of stress riser fractures that occur in regions where stress forces are higher than those in the surrounding material. Most stress riser fractures are related to technical errors (iatrogenic causes) and are difficult to manage. It is possible and more effective to prevent the creation of stress riser fractures through better surgical techniques. The proper terminology for stress fractures, stress riser fractures, periprosthetic fractures, peri-implant fractures, interprosthetic fractures, and interimplant fractures is discussed. This review of the current state of knowledge, diagnosis, treatment, and prevention of stress riser fractures is based on clinical evidence and recent literature.     

Management of hip fractures in the elderly

A fracture of the proximal femur (or hip fracture) is a devastating injury to an elderly patient. Nearly all patients require surgery as part of their treatment but their care necessitates complex multidisciplinary involvement. In the last ten years there have been a number of initiatives to help improve care for this challenging patient group, as well as establishment of The National Hip Fracture Database, to allow us to audit the care provided. With this focus, we have seen both mortality and length of stay decrease. The aim of this article is to summarize the current recommendations for patients who suffer a hip fracture.     

股骨近端骨折后对侧再次骨折

目的　阐述老年性股骨颈和股骨粗隆间骨折后再次对侧股骨近端骨折的发生率、相关因素和临床特征 ,提高对二次骨折的认识和防范。方法　对 1997年 1月～ 2 0 0 1年 10月手术治疗的 4 76例股骨颈骨折和股骨粗隆间骨折病例作回顾性分析 ,针对股骨近端骨折的骨折类型、再次对侧骨折的发生率、骨折时的年龄和性别分布、第一次骨折后再次发生对侧骨折的间隔时间、骨折时的合并症等内容进行研究和比较。结果　 4 76例股骨近端骨折中 ,2 6例为第二次发生的对侧骨折 ,老年性股骨颈和股骨粗隆间骨折后再次对侧股骨近端骨折的发生率为 5 5 % (2 6 / 4 76 )。股骨颈骨折后发生对侧的股骨近端骨折 ,6 8 8% (11/ 16 )的病例仍为股骨颈骨折 ;股骨粗隆间骨折后发生对侧的股骨近端骨折 ,90 0 % (9/ 10 )的病例仍然是股骨粗隆间骨折 ,第二次骨折类型往往同第一次相同。第二次骨折和第一次骨折的时间间隔平均为 2 7年 ,第 2～ 3年发生的占 4 2 3%。单侧和双侧骨折群的年龄和性别无明显差异。白内障、老年性痴呆、Parkinson病、脑血管障碍、脊髓灰质炎后遗症和慢性类风湿性关节炎等合并症的持有率双侧群明显高于单侧群。影响行走功能的合并疾病 ,是再次对侧股骨近端骨折的一个重要易患因素。结论　老年性股骨近端骨折后     

Trochanteric and Subtrochanteric Fractures: One Year Follow-up of a Prospective Study of Ender and McLaughlin Osteosynthesis

The clinical and social status of 110 patients with trochanteric and subtrochanteric fractures was evaluated in a prospective and comparative study 1 year after Ender or McLaughlin osteosynthesis.

In both groups the mortality rate during the first year was 21 per cent. There were no significant differences between the two groups concerning pain, hip movement, walking ability or the social status of the patients. Of the 110 patients surviving the first year, 35 per cent were unable to walk, 20 per cent walked with a cane or crutches and 30 per cent had periodic pains in the hip or knee. About 20 per cent of the patients admitted from their own home now lived in nursing homes.     

Decision-making in burst fractures of the thoracolumbar and lumbar spine

The most common site of injury to the spine is the thoracolumbar junction which is the mechanical transition junction between the rigid thoracic and the more flexible lumbar spine. The lumbar spine is another site which is more prone to injury. Absence of stabilizing articulations with the ribs, lordotic posture and more sagitally oriented facet joints are the most obvious explanations. Burst fractures of the spine account for 14% of all spinal injuries. Though common, thoracolumbar and lumbar burst fractures present a number of important treatment challenges. There has been substantial controversy related to the indications for nonoperative or operative management of these fractures. Disagreement also exists regarding the choice of the surgical approach. A large number of thoracolumbar and lumbar fractures can be treated conservatively while some fractures require surgery. Selecting an appropriate surgical option requires an in-depth understanding of the different methods of decompression, stabilization and/or fusion. Anterior surgery has the advantage of the greatest degree of canal decompression and offers the benefit of limiting the number of motion segments fused. These advantages come at the added cost of increased time for the surgery and the related morbidity of the surgical approach. Posterior surgery enjoys the advantage of being more familiar to the operating surgeons and can be an effective approach. However, the limitations of this approach include inadequate decompression, recurrence of the deformity and implant failure. Though many of the principles are the same, the treatment of low lumbar burst fractures requires some additional consideration due to the difficulty of approaching this region anteriorly. Avoiding complications of these surgeries are another important aspect and can be achieved by following an algorithmic approach to patient assessment, proper radiological examination and precision in decision-making regarding management. A detailed understanding of the mechanism of injury and their unique biomechanical propensities following various forms of treatment can help the spinal surgeon manage such patients effectively and prevent devastating complications.     

Fracture of the talus

Summary A total of 218 talar injuries were studied with particular attention to the nature and extent of associated injuries. In 96 patients (44%) there was a fracture of one of the neighbouring bones, viz. 59 fractures of the ankle, 27 of the calcaneum, and 11 of the navicular. Talar injury, ankle fracture, and calcaneal fracture co-existed in 7 patients. Among the cases complicated by ankle fractures 15 were open (25%) and many affected the trochlea (37%). Thirty-six (61%) of the ankle fractures associated with talar injuries were of the supination type, 8 of the pronation type, 5 of the pronation-external rotation type, and 2 of the supination-external rotation type. Of the talar injuries occurring in a supinated foot about half were shearing fractures of the talar neck. Of the 27 calcaneal fractures 11 were compression fractures with depression of the joint surface, whereas the others were non-displaced shearing fractures or avulsion fractures. It is concluded that as a rule the talar injury is not isolated, but associated with a more extensive regional injury and that a supination force is the decisive factor causing a talar injury.

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Résumé Les auteurs ont étudié 218 traumatismes de l'astragale en tenant particulièrement compte de la nature et de l'étendue des lésions associées. Chez 96 blessés (44%), il existait une fracture d'un os voisin, à savoir: 59 fractures du cou-de-pied, 27 du calcanéum et 11 du scaphoïde tarsien. Sept fois, la lésion astragalienne était associée à une fracture du cou-de-pied et du calcanéum. Parmi les cas compliqués de fractures bimalléolaires, 15 étaient ouverts (25%) et plusieurs (37%) siégeaient au niveau de la poulie astragalienne.Trente-six (61%) des lésions associées du cou-de-pied étaient des fractures par supination, 5 étaient des fractures par pronation et 2 par supination-rotation externe. La moitié environ des traumatismes astragaliens survenus sur un pied en supination étaient des fractures par cisaillement du col de l'astragale. Parmi les 27 fractures du calcanéum, 11 étaient des fractures par compression, avec enfoncement thalamique, tandis que les autres étaient des fractures sans déplacement, par cisaillement, ou des fractures par avulsion.Les auteurs concluent qu'en règle un traumatisme de l'astragale n'est pas isolé mais associé à des lésions régionales plus étendues et qu'une force s'exerçant en supination constitue le facteur déterminant des lésions traumatiques de l'astragale.

     

严重Pilon骨折的手术治疗

目的探讨严重Pilon骨折的不同手术方法、手术时机及治疗效果。方法对1999年5月至2006年6月间46例严重Pilon骨折分别采用有限内固定、有限内固定结合外支架固定及三叶草钢板内固定等方法进行手术治疗。按AO分类方式，所有患者均为C型，C1型10例，C2型22例，C3型14例。开放性骨折11例。闭合性骨折35例。结果所有患者术后均获得8～48个月的随访，平均20个月。踝关节功能按Mazur评价，优21例，良12例，可8例，差5例。主要并发症包括2例皮肤坏死，2例皮肤软组织感染，1例骨感染。5例钉道感染。结论 严重Pilon骨折根据不同的骨折类型、软组织损伤程度及医疗条件选择不同的手术方式和手术时机，均可取得良好的治疗效果。