内倾型后踝骨折的诊断与治疗

 目的 探讨内倾型后踝骨折的特点及治疗方法。方法 回顾性分析2007年5月至2010年12月治疗的75例资料完整的后踝骨折患者资料，筛选出后踝骨折线延伸至内踝的损伤（内倾型后踝骨折）13例，男8例，女5例；年龄15～75岁，平均40.3岁；坠落伤6例，车祸伤4例，扭伤3例；均合并腓骨骨折；12例伴关节软骨面损伤。患者术前临床均表现为踝部及足背部肿胀、畸形、活动受限。正位X线片示骨折线呈冠状位走行，其中10例形成双边征。根据Haraguchi CT分型：Ⅰ型8例（61.6%，8/13），Ⅱ型3例（23%，3/13），Ⅲ型2例（15.4%，2/13）。采用后内侧入路切开，骨折复位后空心钉固定。术后随访切口及骨折愈合情况；采用Baird-Jackson评定标准评价术后疗效。结果 13例患者均获得随访，随访时间8～45个月，平均16个月。术后X线片均示胫骨远端关节面移位＜1 mm，踝穴增宽＜1 mm，骨折达到或者近似解剖复位。13例患者骨折均愈合，愈合时间为12～20周，平均15.1周；切口均为一期愈合。术后Baird-Jackson评分为93～100分，平均96.3分；其中优10例，良3例，优良率为100%（13/13）。末次随访，无一例患者出现感染、骨折再移位、骨不连、螺钉松动及断钉现象。踝关节功能恢复良好，且无需借助辅助工具即可行走。结论 大部分内倾型后踝骨折伴有关节软骨的损伤，这可能是旋转应力合并垂直应力共同作用的结果，需要早期行切开复位内固定治疗，采用后内侧切口治疗具有一定的优越性。

Diagnosis and treatment of the medial-extension type of posterior malleolar fractures

Objective o evaluate the characteristics and treatments of the medial-extension type of posterior malleolar fractures. Methods Data of 75 patients with posterior malleolar fractures from May 2007 to December 2010were retrospectively analyzed. 13 patients whose X-ray showed Cotton fracture while CT scan showed medial-extension type of posterior malleolar fractures were involved in this study. There were 8 males and 5 females, with an average age of 40.3 years old (range, 15-75 years). The mechanisms of injuries were as follow: 6 patients with falling injury, 4 patients from motor vehicle accidents and 3 patients from severe sprain. All the patients combined with distal fibular fracture. The preoperative clinical manifestations included foot and ankle swelling, deformity and restricted movement. The fracture line could be found on coronary X-ray. 10 of those patients had double lines sign in medial malleolus. According to Haraguchi CT scan classification system, 8 patients were Type I fractures (61.6%, 8/13), 3 with Type II fractures (23%, 3/13), and 2 with Type III fractures (15.4%, 2/13). Posterior medial incision, cannulated screws after reduction were conducted. Wound and fracture healing were recorded postoperatively. Function was evaluated according to Baird-Jackson criterion. Results All 13 cases had been followed up for 8-45 months (mean 16 months). Post-operation X-ray showed articular surface displacement was less than 1mm; widening of the medial ankle mortise was no more than 1mm; anatomy reduction was achieved or approximately achieved. All cases got union and the union period was 12-20 weeks with an average of 15.1 weeks. The incisions were primary healed in all patients. According to Baird-Jackson criterion, 10 cases were excellent and 3 were good. 76.9%(10/13) patients got excellent results. No instrument failure, fracture displacement, and infection were found. All patients could walk without accessory appliance. Conclusion Most of medial-extension type of posterior malleolar fractures have articular cartilage damage. It may be caused by rotational force combined with axial load. It needs open reduction and internal fixation early. The posterior medial incision has certain superiority.