胫骨干骨折伴同侧后踝骨折的诊断与治疗

目的 探讨胫骨干骨折伴同侧无移位的后踝骨折的损伤机制与防治. 方法 2001年5月至2004年11月,共收治34例胫骨干骨折伴后踝骨折,2例为开放性骨折.手术前摄胫腓骨全长和踝关节x线片,发现或怀疑有后踝骨折者,均予CT检查,术中先予后踝骨折块经皮螺钉固定,再行胫骨髓内钉手术治疗. 结果所有患者平均随访时间11个月.33例患者骨折愈合良好,踝关节功能优良.1例患者术前漏诊,随访时发现后踝骨折,踝关节疼痛功能差. 结论胫骨干合并后踝骨折在临床常见,后踝骨折漏诊是后期踝关节功能障碍的主要原因,术前踝关节CT检查及术中后踝精确固定是防治的关键.     

胫骨下段骨折合并隐匿后踝骨折临床分析探讨

[目的]探讨胫骨下段螺旋形骨折合并后踝骨折的漏诊原因及治疗策略。[方法]回顾性分析2010年6月~2014年11月收治的11例胫骨下段骨折合并后踝骨折的诊治过程。[结果]9例于术前发现后踝骨折,2例于术中发现。经皮空心无头加压钉内固定后踝10例,1例经解剖钢板结合孔固定后踝,术后未发现骨折块明显移位。平均随访16.5个月,后踝骨折均获骨性愈合,1例胫骨骨折迟缓愈合。[结论]胫骨下段螺旋形骨折常合并隐匿的后踝骨折,单纯X线检查易漏诊,CT检查可明确诊断。后踝骨折无论是否移位,固定都是必须的,经皮空心无头加压钉固定是一种有效的治疗方式。     

胫骨中下段骨折合并后踝骨折的诊治体会

目的探讨胫骨中下段骨折合并后踝骨折的发生机制、治疗方案、漏诊原因及应对方法。方法深圳市南山区蛇口人民医院自2011年1月至2013年12月收治胫骨中下段骨折患者56例,其中合并后踝骨折17例,包括术前漏诊后踝骨折8例,其中4例术中发现,另外4例术后复查CT发现。7例采用髓内钉固定,10例钢板固定;后踝骨折采用钢板固定10例,拉力螺钉固定4例,钢板及螺钉固定1例,另2例采用踝关节背伸位石膏固定;腓骨骨折均未作处理。治疗效果采用Olerud-Molander踝关节骨折疗效评分系统进行评价。结果本组病例胫骨中下段骨折合并后踝骨折发病率30.36%,漏诊率47.06%,其中螺旋形胫骨中下段骨折合并后踝骨折发病率39.5%,17例患者均获得随访,随访时间6~42个月,平均(32±4.6)个月。所有患者均获得骨性愈合,2例保守治疗患者术后复查踝关节正侧位片示关节面对位欠佳,对线良好,其余病例关节面均对位对线良好。疗效结果评价优良率88.2%。结论胫骨中下段骨折合并后踝骨折发病率高,特别对于螺旋形胫骨中下段骨折,需要高度警惕合并隐匿性后踝骨折,建议常规行CT检查;后踝骨折应解剖复位、坚强固定,对于手术治疗本研究尚不能区别螺钉与钢板的固定效果;如发生漏诊,应及早处理,以免发生创伤性关节炎。     

胫前微创空心拉力螺钉治疗合并胫骨下1/3螺旋形骨折的后踝骨折

[目的]探讨在胫骨下1/3螺旋形骨折合并后踝骨折病人使用胫前微创空心拉力螺钉固定后踝骨块的临床效果.[方法]自2007年9月～2009年9月,采用胫前小切口空心拉力螺钉固定合并于胫骨中下段骨折的后踝骨折23例.男15例,女8例,年龄23～ 48岁,平均36.2岁,合并腓骨下段骨折11例,上段骨折7例.根据Leeds提出的标准进行疗效评价.[结果]随访时间为14 ～ 38个月,平均25.7个月.骨折全部愈合,无骨不连、感染断钉等情况.疗效根据Leeds提出的标准进行评定,优占73.9％,良占17.4％,差占8.7％,优良率91.3％.[结论]微创技术使用胫前空心拉力螺钉固定是治疗胫骨下1/3螺旋形骨折合并后踝骨折的有效方法之一.     

前外侧L形解剖锁定钢板治疗胫骨中下段螺旋形骨折合并后踝骨折的疗效

目的 探讨前外侧L形解剖锁定钢板治疗胫骨中下段螺旋形骨折合并后踝骨折的疗效.方法 采用前外侧L形解剖锁定钢板治疗29例胫骨中下段螺旋形骨折合并后踝骨折患者.记录切口长度、术中出血量、手术时间、住院费用、骨痂形成时间、骨折愈合时间、并发症发生情况.采用AOFAS踝-后足评分、疼痛VAS评分、踝关节活动度评价临床疗效.结果...     

胫骨中下1/3骨折合并后踝骨折两种手术方法比较

目的比较胫骨中下1/3骨折合并后踝骨折2种手术方法的疗效。方法手术治疗33例胫骨中下1/3骨折伴后踝骨折,其中胫骨骨折采用钢板内固定,后踝采用空心钉内固定18例(空心钉组)和切开复位钢板固定15例(钢板组)。采用AOFAS评分评价踝关节功能。结果术后33例获随访10~28个月,平均18.5个月。骨折均愈合,无骨折延迟愈合或不愈合。踝关节功能按照AOFAS评分标准评定:空心钉组优9例,良6例,可2例,差1例,优良率83.3%;钢板组优8例,良5例,可1例,差1例,优良率86.7%。两组AOFAS评分优良率差异无统计学意义(P=0.18>0.05)。结论胫骨中下1/3骨折常合并后踝骨折,后踝骨折采用空心钉和钢板内固定治疗临床疗效上无明显差异,空心钉内固定损伤小,而钢板内固定更加切实可靠。     

髓内钉加空心螺钉治疗胫骨下1/3螺旋形骨折合并后踝骨折

[目的]探讨胫骨髓内钉加空心螺钉治疗胫骨下1/3螺旋形骨折合并后踝骨折的临床效果,并比较标准髓内钉(S)与半伸直位髓内钉(SE)的疗效差异。[方法]回顾性分析本院骨科自2010年1月~2014年5月收治的98例胫骨下1/3螺旋形骨折的患者,经术前影像学检查合并后踝骨折而纳入本组研究共56例。其中35例采用标准髓内钉加空心螺钉固定,21例采用半伸直位髓内钉加空心螺钉固定。分别从失血量、手术时间、平均住院日、骨折愈合时间、膝踝关节功能评分方面比较两组的治疗效果。[结果]56例患者均获随访,时间12~18个月,平均15.6个月。两组失血量比较差异无统计学意义(P=0.86),半伸直位髓内钉组手术时间明显短于标准髓内钉组(P=0.000.05)。平均住院日、骨折愈合时间两组间比较差异无统计学意义(P=0.42,P=0.17),膝踝关节功能评分两组间比较差异无统计学意义(P=0.12,P=0.31)。后踝骨折均愈合并没有发生骨折移位。1例出现后踝空心螺钉退钉,1例出现迟发性皮肤软组织感染,经抗感染治疗后痊愈。[结论]胫骨下1/3螺旋形骨折合并后踝骨折发生率高,易漏诊,术前应常规行CT检查。髓内钉加空心螺钉治疗此类损伤可以收到满意的效果,治疗胫骨下1/3螺旋形骨折半伸直位髓内钉较标准髓内钉更有优势。     

胫骨干骨折合并同侧后踝骨折17例临床分析

胫骨干骨折合并同侧后踝骨折常因发生率低及后踝无明显移位极易被漏诊,治疗不当后踝移位导致踝关节创伤性关节炎的发生.笔者自2005年1月～2008年9月收治胫骨干骨折合并同侧后踝骨折17例,采用髓内钉结合空心钉内固定治疗,取得满意疗效.现报告如下.     

踝关节骨折手术治疗中后踝螺钉固定异常的表现

目的 总结在踝关节骨折手术治疗中后踝螺钉固定时位置异常的发生情况. 方法 回顾性分析2011年1月1日至12月31日收治的417例(421侧)踝关节骨折患者的临床资料,男217例219侧,女200例202侧;年龄14 ～85岁,平均41岁;右侧223例,左侧198例.术前进行CT检查的368侧骨折中有后踝骨折299侧,其中实际采用螺钉固定的后踝骨折有131侧.分析后踝骨折患者术后X线片和CT扫描图像等影像学资料,观察后踝螺钉固定位置异常的影像学表现. 结果 螺钉位置异常的CT图像表现为螺钉头和杆部进入下胫腓间隙内,X线片表现为螺钉头位于胫骨腓骨切迹后侧缘的外侧.在131侧采用螺钉固定的后踝骨折中,通过CT检查和X线片检查所发现的后踝螺钉固定位置异常分别为7侧和6侧(9.9％,13/131),其中9侧(69.2％,9/13)为经皮固定. 结论 手术固定后踝骨折存在螺钉固定位置不良的可能性,术中透视确认螺钉头位于胫骨后结节的胫骨侧可能有助于减少其发生.     

后外侧入路空心钉内固定治疗下胫腓后韧带止点撕脱后踝骨折

目的探讨后外侧入路空心钉内固定治疗下胫腓后韧带止点撕脱后踝骨折的疗效。方法采用后外侧入路空心钉内固定治疗26例三踝骨折中下胫腓后韧带止点撕脱后踝骨折,先行内、外踝骨折内固定,再行后踝骨折固定。结果本组均获平均15(10~24)个月随访,未出现切口感染、皮肤坏死等并发症。术后随访X线片未见内固定失败、断裂。踝关节骨折均于术后3~4个月愈合,平均3.5个月。结论后外侧入路空心钉内固定治疗下胫腓后韧带止点撕脱后踝骨折操作方便、复位精确、固定可靠,值得进一步推广。     

Distal articular involvement in tibial shaft fractures: an evaluation of 125 consecutive cases

Purpose

To report the incidence and morphology of ipsilateral distal articular involvement (DAI) in a consecutive series of tibial shaft fractures.

Method

A retrospective review was performed on 115 patients who underwent intramedullary nailing for tibia shaft fractures. Ankle evaluations included preoperative radiographs and computed tomography (CT) scans in all patients.

Results

Thirty-two patients (27.8%) in our series presented with tibial shaft fractures associated with DAI. Tibial spiral fractures (42A1) were significantly related to DAI (RR: 1788). In 28 (87.5%; 28/32) articular fractures, posterior malleolus fractures (PMF) were present; 22 were isolated, and six (18.8%) occurred in combination with medial malleolus or anterolateral fractures. The remaining (12.5%; 4/32) were isolated medial malleolus fractures. Ten (31.2%; 10/32) articular fractures were occult on the radiographs and only detected on CT scan.

Conclusion

DAI is common in tibial shaft fractures. CT evaluation is mandatory due to the high number of occult fractures. Although isolated PMF is the most frequent pattern of DAI involvement, 31.3% of the cases exhibited different patterns.

     

后内侧解剖板治疗陈旧后踝骨折伴踝关节脱位

目的探讨胫骨远端后内侧解剖板治疗陈旧性后踝骨折伴踝关节后脱位的临床疗效。方法采用小腿后内侧入路胫骨远端后内侧解剖型钢板内固定,对16例陈旧性后踝骨折伴踝关节后脱位患者进行手术治疗。结果术后随访8～24个月（平均12个月）,所有伤口均一期愈合,无皮肤坏死、伤口感染、钢板外露等严重并发症。骨折临床愈合时间10～16周,平均12周。按Mazur踝关节功能评定标准进行评价,本组优12例,良3例,可1例,优良率93．75％。结论胫骨远端内后侧解剖型板符合胫骨远端内后侧的解剖形态,起到一种压板效应,能使陈旧后踝骨折块容易复位,固定确切可靠,符合后踝骨折固定的生物力学原理,对于陈旧后踝骨折伴踩关节后脱位具有明显的优越性。     

预置阻挡钉在治疗胫骨螺旋形骨折合并后踝骨折中的作用

目的探讨预置阻挡钉在治疗胫骨中下1/3螺旋形骨折合并后踝骨折中的作用。方法回顾性分析2018年5月至2020年6月收治的24例胫骨中下1/3螺旋形骨折合并后踝骨折患者临床资料。所有患者均采用预置阻挡钉技术,并进行髓内钉及空心钉内固定治疗。术后记录胫骨正位X线片上冠状面力线(胫骨远端外侧角)、膝关节疼痛视觉模拟评分(VAS)、患肢踝关节背屈活动受限角度和美国矫形外科足踝协会(AOFAS)踝-后足评分评价疗效。结果所有患者均直接获得骨折端复位,未发生感染、内固定失败、骨折畸形愈合、创伤性关节炎等并发症。术后基于X线片测得的胫骨远端外侧角平均89.3°±4.2°,膝关节VAS评分平均(1.4±0.5)分,踝关节背屈活动受限平均6.8°±1.7°;AOFAS踝-后足评分平均(92.3±5.8)分,优良率为91.7%。结论预置阻挡钉可有效协助骨折复位,恢复下肢力线,联合髓内钉及空心钉内固定治疗胫骨中下1/3螺旋形骨折合并后踝骨折,可获得满意疗效。     

Posterior malleolar fracture is often associated with spiral tibial diaphyseal fracture: a retrospective study

BACKGROUND: It is known that posterior malleolar fracture is often associated with tibial diaphyseal fractures. However, in literature there are very few studies on tibial shaft fractures with respect to posterior malleolus fragment. We hypothesized that the incidence of posterior malleolar fracture is higher than in previous studies. METHODS: A total of 74 closed tibial shaft fractures were treated with intramedullary nailing in Turku University Central Hospital between January 1994 and December 1998. There were 55 men and 19 women, with a mean age of 39 years (range, 16 to 58 years). Two cases were excluded and 72 tibial shaft fractures were analyzed retrospectively. RESULTS: Posterior malleolar fracture was observed in 18 cases (25.0%). Only 10 were observed preoperatively in plain films, seven were detected postoperatively and one was not detected at all during the treatment. Retrospectively, all 18 posterior malleolar fractures were detectable in preoperative plain films. CONCLUSION: A fracture of the posterior malleolus was involved in every fourth tibial diaphyseal fracture. The fractures of the posterior malleolus were always detected in preoperative plain films and should be suspected, especially in cases of low-energy spiral distal tibial diaphyseal fractures. We recommend additional plain films to be taken at the ankle region to better visualize these fractures.     

交锁髓内钉和经皮钢板固定治疗胫骨远端干骺端骨折的疗效比较

目的 比较交锁髓内钉和经皮钢板固定治疗胫骨远端干骺端骨折的疗效。方法 回顾性分析2004年5月～2005年8月采用交锁髓内钉或经皮钢板固定的51例胫骨远端干骺端骨折的治疗效果，根据内固定方式分成髓内钉组（n=27）和钢板组（n=24），比较两组的手术时间，出血量，透视次数，骨折愈合时间，踝关节前后向、内外翻成角，踝关节最大背伸度及并发症，并采用Olerud-Molander踝关节评分评价结果。结果 所有患者获得12—27个月（21．2个月）随访，两组患者在手术时间、透视次数、踝关节最大背伸度方面差异无统计学意义（P〉0．05）。所有骨折均获得愈合，平均愈合时间髓内钉组为20．0周，钢板组为18．6周。Olerud-Molander踝关节评分结果均为优良。髓内钉组具有较少的手术出血量，钢板组具有更好的骨折对线；髓内钉组有5例发生畸形愈合，钢板组有4例发生局部软组织并发症。结论 对于胫骨远端骨折，交锁髓内钉和经皮钢板固定都是有效的固定方式，经皮钢板能够提供更好的骨折端稳定性，而交锁髓内钉有利于处理伴有局部软组织损伤的骨折。     

CT和MRI在胫腓骨螺旋骨折合并后踝隐匿性骨折中的诊断价值

目的 探讨CT、MRI在胫腓骨螺旋骨折合并后踝隐匿性骨折中的诊断价值.方法 对2007年7月至12月收治的39例胫腓骨螺旋骨折合并后踝隐匿性骨折患者的资料进行分析,其中男30例,女9例;平均年龄39.9岁;左侧15例,右侧24例.39例患者术前均行X线、CT和MRI检查,根据结果做出诊断并分别统计上述方法对后踝隐匿性骨折的显示情况. 结果 本组胫腓骨螺旋骨折同时合并后踝骨折30例,胫骨螺旋骨折合并后踝骨折7例,腓骨螺旋骨折合并后踝骨折2例.患者后踝均为斜形裂纹骨折,其中长斜形骨折30例,短斜形骨折9例;后踝骨折轻度分离7例.X线片、CT、MRI对后踝骨折的诊断准确率分别为10.3%、94.9%、100%,假阴性率分别是89.7%、5.1%、0,假阳性率均为0. 结论 CT、MRI可以提高胫腓骨螺旋骨折患者合并后踝隐匿性骨折的诊断率.MRI是显示后踝隐匿性骨折最敏感的检查方法.     

腓骨远端干骺端钢板固定外踝和后踝治疗三踝骨折

目的探讨腓骨远端干骺端钢板用作支撑钢板固定外踝和后踝治疗三踝骨折的疗效及预后。方法 2008年1月至2010年1月,采用腓骨远端干骺端钢板用作支撑钢板固定外踝及后踝治疗三踝骨折23例,男10例,女13例;年龄20～65岁,平均45岁。左侧12例,右侧11例。根据Lange-Hansen分型,Ⅲ、Ⅳ度旋后-外旋型14例,Ⅳ度旋前-外旋型9例。直视下行骨折复位内固定,骨折复位固定顺序为外踝、后踝、内踝、下胫腓联合。术后随访观察骨折愈合及钢板稳定情况。结果所有病例得到随访,随访时间12～36个月,平均28.4个月。患肢均无畸形愈合,无骨不连,无钢板外露、松动、断裂,无伤口感染。根据Baird-Jackson评分系统进行评估,优17例,良4例,可2例,优良率为91%。结论腓骨远端干骺端钢板用作支撑钢板固定外踝及后踝治疗三踝骨折,其操作简便、对骨折固定可靠、踝关节功能恢复满意、并发症少,是治疗三踝骨折的有效方法。     

胫骨远端后内侧解剖接骨板固定后踝治疗三踝骨折

目的探讨胫骨远端后内侧解剖接骨板固定后踝治疗三踝骨折的临床效果。方法2007年2月至2009年1月采用胫骨远端后内侧解剖接骨板固定后踝治疗三踝骨折患者11例,男7例,女4例;年龄23～58岁,平均41岁;左踝5例,右踝6例;开放骨折2例,闭合骨折9例。根据Lauge-Hansen分型均为旋前外旋型Ⅳ度,后踝骨折均超过关节面的25%。结果全部获得随访,随访时间为11～26个月,平均15.8个月。伤口均一期愈合,无一例发生感染。骨折愈合时间为10～15周,平均11.6周。术后采用AOFAS踝关节-后足评分标准,评分为83～100分,平均87.2分。结论胫骨远端后内侧解剖接骨板固定后踝是治疗三踝骨折的有效方法之一。     

Distal Tibial Fractures: Intramedullary Nailing

The tibia is an exposed bone with vulnerable soft tissue coverage and is therefore predisposed to local soft tissue problems and delayed bone healing. The objective in distal tibial fracture treatment is to achieve stable fixation patterns with a minimum of soft-tissue affection. Thus, the risk of soft tissue breakdown and bone healing complications is more likely related to open reduction and plating. Percutaneous, minimally invasive intramedullary nailing is a proven fixation mode for fracture stabilization in tibial shaft fractures. Anticipating the pitfalls, intramedullary nailing meets the requirements of the method of choice in distal tibial fracture fixation. In conclusion, intramedullary nailing of distal tibial fractures is a reliable method of fixation, possessing the advantages of closed reduction and symmetric fracture stabilization of an area with a delicate soft tissue situation, but prospective randomized trials are needed to compare modern intramedullary fracture fixation with modern plate fixation in distal tibial fractures.     

Does fibular plating improve alignment after intramedullary nailing of distal metaphyseal tibia fractures?

OBJECTIVE: Evaluate whether supplementary fibular fixation helped maintain axial alignment in distal metaphyseal tibia-fibula fractures treated by locked intramedullary nailing. DESIGN: Retrospective chart and radiographic review. SETTING: Three, level 1, trauma centers. PATIENTS: Distal metaphyseal tibia-fibula fractures were separated into 2 groups based on the presence of adjunctive fibular plating. Group 1 consisted of fractures treated with small fragment plate fixation of the fibula and intramedullary (IM) nailing of the tibia, whereas group 2 consisted of fractures treated with IM nailing of the tibia without fibular fixation. OUTCOME MEASURES: Malalignment of the tibial shaft was defined as 1) >5 degrees of varus/valgus angulation, or 2) >10 degrees anterior/posterior angulation. Measures of angulation were obtained from radiographs taken immediately after the surgery, a second time 3 months later, and at 6-month follow-up. Leg length and rotational deformity were not examined. RESULTS: Seventy-two fractures were studied. In 25 cases, the associated fibula fracture was stabilized, and in 47 cases the associated fibula fracture was not stabilized. Cases were more likely to have the associated fibula fracture stabilized where the tibia fracture was very distal. In multivariate adjusted analysis, plating of the fibula fracture was significantly associated with maintenance of reduction 12 weeks or later after surgery (odds ratio = 0.03; P = 0.036). The use of 2 medial-lateral distal locking bolts also was protective against loss of reduction; however, this association was not statistically significant (odds ratio = 0.29; P = 0.275). CONCLUSIONS: In this study, the proportion of fractures that lost alignment was smaller among those receiving stabilization of the fibula in conjunction with IM nailing compared with those receiving IM nailing alone. Adjunctive fibular stabilization was associated significantly with the ability to maintain fracture reduction beyond 12 weeks. At the present time, the authors recommend fibular plating whenever IM nailing is contemplated in the unstable distal tibia-fibular fracture.