胫骨Pilon骨折的治疗现状与进展

胫骨Pilon骨折是指胫骨远端1/3波及胫距关节面的骨折,常合并有腓骨下段骨折和严重的软组织挫伤。按Ruedi-Allgower的分类法分3型;Ⅰ型:较少移位;Ⅱ型:明显的关节面移位而粉碎程度较小;Ⅲ型:关节面粉碎移位及粉碎程度均较严重。胫骨pilon骨折约占下肢骨折的1％～     

Pilon骨折

胫骨Pilon骨折一般是指胫骨远端1／3波及胫距关节面的骨折,胫骨远端关节面严重粉碎,骨缺损及远端松质骨压缩。常合并有腓骨下段骨折（约75％-85％）和严重软组织挫伤。Pilon骨折应包括：（1）踝关节和胫骨远端的干骺端骨折,通常伴有踝关节的关节面粉碎性骨折;（2）内踝骨折;（3）胫骨前缘骨折;（4）胫骨后面横形骨折。     

胫骨Pilon骨折的治疗现状与进展

胫骨Pilon骨折是指胫骨远端1/3波及胫距关节面的骨折,常合并有腓骨下段骨折和严重的软组织挫伤.按Ruedi-Allgower的分类法[1]分3型;Ⅰ型:较少移位;Ⅱ型:明显的关节面移位而粉碎程度较小;Ⅲ型:关节面粉碎移位及粉碎程度均较严重.胫骨pilon骨折约占下肢骨折的1%～10%[2],在胫骨和踝关节骨折中占4%～7%[3,4],随着交通运输和工农业生产的发展,由高能量暴力造成的该部位骨折有增多的趋势,而且伤情更加复杂、并发症多、致残率高,是最难治疗的骨折之一[4,5],由于胫骨远端血供差、软组织薄,不能提供良好的血运及保护,而且关节面嵌压,严重粉碎,以致于pilon骨折治疗极其困难.近年来,国内外学者对此类骨折的治疗方法、固定器械和固定材料的改进等方面取得了明显的成效,现将有关治疗进展综述如下.     

Pilon骨折的分类与功能评价

Pilon骨折的概念由Destot于1911年提出，其特征是涉及胫骨远端关节面上干骺端骨折，呈现不同程度的嵌插与粉碎，伴有关节软骨损伤和关节面分离，可涉及内踝、外踝、后踝的骨折。Pilon骨折的分类，目前临床应用较多的是Rtiedi-Allgoewer分类(1969)与AO／OTA分类方法(1996)。Rueedi-Allgoewer分类依据关节面的粉碎程度和移位程度，将Pilon骨折分为三型。AO／OTA分类中，Pilon骨折主要涉及43-B3、43-C1、43-C2、43-C3，共分为两型4组12个亚组。Pilon骨折治疗结局评价主要用Burwell-Charnley(1965)骨折复位放射学评价标准和Tornetta(1993)临床治疗结果评价标准，也可用Mazur(1979)踝关节评价分级系统、Baird-Jackson(1987)踝关节评分系统。     

移位型Pilon骨折的治疗

Ｐｉｌｏｎ骨折是指踝关节中立位受到轴向应力造成胫骨远端经关节面不同程度的爆裂性骨折。Ｒｕｅｄｉ和Ａｌｌｇｏｗｅｒ把Ｐｉ ｌｏｎ骨折分为三型[1] :Ⅰ型劈裂骨折无关节面移位 ;Ⅱ型关节面严重骨折移位无粉碎 ;Ⅲ型胫骨远端压缩和粉碎性骨折。Ⅱ、Ⅲ型骨折我们称之为移位型Ｐｉｌｏｎ骨折。Ⅰ型骨折多经保守治疗 ,疗效较好 ,已被认可[1～ 5] ,但对Ⅱ、Ⅲ型骨折治疗则相当棘手 ,如处理不当 ,常继发创伤性关节炎。我院自 1990年以来收治移位型Ｐｉｌｏｎ骨折 2 5例 ,采用开放解剖重建、坚强内固定和早期功能康复治疗 ,优良率达 84 %。报…     

胫骨Pillon骨折

Pillon骨折是涉及负重关节面与干骺端的胫骨远端骨折，其典型特征是干骺端存在不同程度的压缩，干骺端的压缩粉碎性骨折、不稳定、原发性关节软骨损伤以及永久性关节面不平整导致预后不良。Pillon骨折的发生率较低，约占下肢骨折的1％及胫骨骨折的7％～10％。近年来，有关Pillon骨折的临床研究非常活跃，本文拟就有关文献做一综述。     

复杂Pilon骨折的治疗策略

Pilon骨折是指累及胫骨远端负重关节面的骨折,约占所有下肢骨折的1%,占胫骨骨折的3%～10%[1].Bartlett 等[2]将Pilon骨折的特征总结为涉及胫骨远端关节面的干骺端骨折,有不同程度的嵌插;呈粉碎、不稳定性,关节软骨损伤、关节表面不平;骨折可涉及内、外、后踝;75%～85%的患者可伴有腓骨骨折.复杂Pilon骨折主要是指胫骨负重关节面严重破坏、伴有大量干骺端骨块压缩、周围软组织严重损伤、预后较差的一类Pilon骨折[3].     

中西医结合治疗Pilon骨折97例

Pilon骨折为胫骨远端经关节面粉碎骨折和腓骨下1/3骨折,由于胫骨远端关节面爆裂,难以恢复平滑的关节面,易发生骨不连、切口皮肤坏死、感染和关节功能障碍等并发症。2006年1月—2011年10月,我们采用中西医结合方法治疗Pilon骨折97例,疗效满意。     

Meta接骨板治疗Pilon骨折的初步体会

[目的]探讨应用Meta接骨板治疗Pilon骨折的临床疗效.[方法]23例Pilon骨折按Ruedi-Allgower分型[1],其中Ⅰ型（劈裂骨折,骨折间移位轻微）2例,Ⅱ型（关节内骨折中度移位,但未粉碎）13例,Ⅲ型（Ⅱ型基础上有胫骨远端的粉碎和关节面的压缩）8例.采用切开复位强生Meta接骨板内固定治疗,术后早期行不负重的踝关节功能练习.[结果]术后随访18～24个月,踝关节功能根据Mazur标准评判[2],23例患者总优良率87%.并发症主要有：5例伤口浅表感染,3例发生踝关节创伤性关节炎.[结论]对于Ruedi-Allgower Ⅱ、Ⅲ型Pilon骨折,运用Meta接骨板治疗Pilon骨折可取得满意的疗效.     

三叶形钢板内固定治疗胫骨Pilon骨折17例体会

胫骨Pilon骨折是指波及关节面的胫骨远端骨折。常合并有腓骨下段骨折和严重的软组织损伤。其典型特征是干骺端存在不同程度的压缩。干骺端的压缩粉碎性骨折、不稳定、原发性关节软骨损伤以及永久性关节面不平整，导致预后不良。Pilon骨折的发生率较低，约占下肢骨折的1％。本院自1999年6月至2005年12月，采用三叶形内固定治疗胫骨Pilon骨折17例，获得了良好疗效。     

C2,3椎弓根固定治疗不稳定性Hangman骨折

目的 探讨C23椎弓根固定术治疗不稳定性Hangman骨折的疗效.方法 2001年10月至2005年10月,治疗不稳定性Hangman骨折患者26例,男18例,女8例;年龄21～56岁,平均38.5岁.根据Levine等分型标准Ⅱ型11例,ⅡA型10例,Ⅲ型5例.脊髓功能Frankel分级,D级6例,E级20例.采用后侧入路,在"C"型臂X线机监视下复位骨折后,采用Axis或Vertex系统经C2,3椎弓根螺钉固定,行椎板间和关节突间植骨融合.以C2侧块中点为进针点,进针方向为向头端倾斜15°～25°,向中线倾斜20°～25°;螺钉长度为26～30 mm,直径为3.5～4.0 mm.以C3侧块的外上象限中点为进针点,水平面上进针方向为向头端内侧倾斜35°～45°,矢状面上丝锥在C3向头侧倾斜约10°,进深为20～25mm,长度为18～24 mm,直径为3.5～4.0 mm.结果 术后骨折复位满意,且全部愈合,颈椎功能无明显受限,无一例发生脊髓及椎动脉损伤.6例术前有神经症状者术后1周均有不同程度恢复.随访6～54个月,平均29个月.6例术前脊髓功能Frankel分级为D级的患者术后恢复至E级.术后CT检查示C2椎弓根螺钉偏外3枚(3/52);C3椎弓根螺钉偏外进入横突孔7枚(7/52);未发现螺钉偏内病例.按Mayo(McGrory)颈椎创伤后临床评价标准评分,优16例,良7例,可3例,优良率88.46%.结论 经C2,3椎弓根固定治疗不稳定性Hangman骨折可获得满意疗效.     

Hepatitis C

Trauma und Berufskrankheit - Die Hepatitis C ist weltweit verbreitet. In Europa sind etwa 9 Mio. Menschen infiziert. Der Erreger wird parenteral und verdeckt parenteral übertragen....     

Hepatitis C

Hepatitis C has spread throughout the world. In Europe about 9 million people are infected. The pathogen is transmitted parenterally and by covert parenteral routes. The infection takes a chronic course in about 80% of those affected; 20% develop liver cirrhosis, 1–4% of whom each year then also develop hepatocellular carcinoma. The course of the transaminases in hepatitis C can be constantly normal or pathologic, or fluctuate. In 20% of the patients with consistently normal transaminase activities the illness takes a progressive course despite the inconspicuous laboratory chemistry. In these cases, as in patients with progressive disease and high amino transaminase activities, treatment should be considered. Treatment today is individualized and tailored to the HCV genotype with a combination of a pegylated interferon and ribavirin. Extrahepatic manifestations of chronic HCV infection are rare.     

Management of spine fractures C3 to C7

The goals of management of spine fractures from C3 to C7 are to provide stability for maximum pain-free function and to prevent further or future injury to the spinal cord and nerve roots. Surgical fusion may be necessary to provide immediate and long-term stability. Posterior instability should be treated by posterior fusion, and anterior instability should be treated with anterior stabilization.     

Fractures of the C1 and C2 Vertebrae

Upper cervical fractures of the axis and atlas (C1 and C2, respectively) typically occur in children and in the elderly population. The anatomic characteristics of the craniocervical junction allows for unique fracture patterns. Jefferson fractures of the atlas are the classic fracture presentation of the C1 vertebrae. Odontoid fractures and traumatic spondylolisthesis of the axis are the most commonly reported fractures of the C2 vertebrae. This chapter will review the anatomy, injury mechanisms, and fracture types seen in the C1 and C2 vertebrae. In addition, several nonoperative and operative treatment options, supported by the literature, will be discussed.     

Surgical stabilization of C1 and C2 fractures

We present operative procedures for the stabilization of fractures of C1 and C2. As is the case for fractures of the extremities, a direct approach to the injury should be attempted in order to avoid the inclusion of intact segments in the spondylodesis. The aim of the three presented techniques - direct screw fixation of fracture of the dens axis and traumatic lysis of C2 - is to active anatomical reconstruction by optimal stabilization. The new technique of transarticular screw fixation of C1-2 developed by Magerl allows unisegmental three-dimensional stabilization in cases in which at least a three-level fusion would have previously been considered necessary.     

Ganglioneuroma of the C4, C5 interspace

Neurogenic tumors in the neck region are relatively infrequent with the exception of those involving the cranial nerves. A case of a ganglioneuroma or neurofibroma involving the nerve root of C4, C5 interspace is reported. The tumor appeared as a mass within the neck with a slight amount of pain in the shoulder and upper arm upon palpation. Surgical exploration revealed a mass superficial to the foramen and erosion of the foramen. Roentgenograms taken in the region demonstrated an extradural mass that was subsequently removed by laminectomy. Postoperatively, the patient did quite well. Surgical excision is the treatment of choice. Preservation of the nerve should be accomplished if at all possible.