胫腓骨骨折并发胫后血管损伤的临床诊治

目的总结中下段胫腓骨骨折合并胫后血管损伤的诊治经验。方法对58例中下段胫腓骨骨折合并胫后血管损伤患者的术前诊断、术中探查结果、治疗方法选择及治疗结果进行经验总结。结果血管损伤类型：血管卡压16例,血管挫伤7例,其中血栓形成5例,血管完全断裂35例。术后58例患肢均完全成活。随访6个月～2年,55例出现不同程度足踝及（或）足趾屈曲挛缩畸形。发生踝关节屈曲挛缩19例,行手术矫形16例;足趾屈曲畸形35例,手术矫形13例,均为小腿中段骨折病例。结论较严重的胫骨骨折常伴有不同程度的胫后血管损伤,及时手术探察修复是避免漏诊和减少术后并发症的有效手段。     

胫腓骨近端骨折合并腘部血管伤14例报告

1977至1987年,笔者共收治合并腘部血管伤的胫腓骨骨折14例,其中重建血运成功肢体成活8例,血运重建失败截肢2例,入院时肢体已坏死行截肢2例,单纯小腿筋膜间隔切开减压无效截肢1例,合并急性肾功能衰竭治疗无效死亡1例.本组14例中男13例,女1例.闭合骨折6例,开放骨折8例.骨折位于近1/4,而远段向后上方移位者4例;粉碎性骨折片显著移位10例,血管损伤部位为腘动脉或胫前、胫后动脉,其中4例伴有腘静脉破裂.     

闭合性腘动脉损伤的诊断与治疗

目的探讨闭合性腘动脉损伤的诊断与治疗。方法收治26例闭合性腘动脉损伤患者,13例采用彩色多普勒超声检查明确血管损伤部位,8例DSA检查明确损伤部位,5例直接手术探查。11例行断端吻合,14例大隐静脉移植,25例均行预防性小腿切开减张。术后应用激素、甘露醇等治疗。结果 22例15h内手术者均成功保肢,并且功能良好,3例24～36h内手术者2例保肢成功,1例截肢,72h明确诊断者肢体坏死直接行截肢手术。结论闭合性腘动脉损伤只要肢体不出现坏死,一旦确诊均应尽早修复血管以求保肢可能。     

单纯腓肠神经筋膜瓣修复足踝部软组织缺损一例

患者男,40岁,双下肢车祸致伤1h。入院检查:左下肢自髁上至足部皮肤完全裂伤,窝肌肉、血管、神经完全挫伤,右足自踝上至足底皮肤完全撕脱,胫后动脉及神经挫伤缺损。X线示:右侧腓骨、内踝骨折;左侧股骨、胫腓骨骨折。治疗在积极抗休克治疗下,急诊行右足清创,左下肢截肢术。探查     

下肢外伤性缺血截肢原因分析

我院自 1989年 7月～ 1994年 12月治疗合并有重要血管损伤的患者 2 0例 ,行下肢截肢 ,分析其原因如下。1　临床资料1 1　一般资料　本组 2 0例中 ,男 19例 ,女 1例 ;年龄 4～ 5 2岁 ,平均 30 2岁。开放损伤 19例 ,闭合性损伤 1例 ;股骨中下段骨折 8例 ,胫腓骨骨折 11例 ;其中不完全离断伤 6例 ,完全离断伤 2例。1 2　血管损伤　 2 0例中有血管损伤 19例 ,1例为小腿骨筋膜室综合征 ;动脉损伤 16例 ,股动脉损伤 2例 ,胫前动脉与胫后动脉损伤 1例。1 3　肢体缺血临床表现　根据比企提出缺血六项证候依次表现为脉搏消失 18例 ,肢端较凉 13例 …     

胫骨缺损性不连接的手术治疗

因开放性胫腓骨骨折或伴有感染造成胫骨缺损性不连接 ,治疗较为麻烦 ,我们采用胫腓上下关节融合及胫骨大块植骨治疗了 11例病例均获得成功 ,伤肢功能良好 ,现报告如下。1　临床资料1 1　一般资料　 11例中均为男性 ,年龄 2 6～ 5 8岁 ,平均 36岁。开放性骨折术后感染造成胫骨缺损 6例 ,交通伤造成骨缺损 4例 ,胫腓骨骨折后感染不连接 ,行髂骨血管植骨再次感染死骨摘除不连 1例。胫骨缺损 40～ 70ｍｍ。其中有 1例胫腓骨均不连接。1 2　治疗方法　先处理软组织 ,血供差 ,疤痕粘连 ,手术区条件血供不良则先作皮管成形术逐步转移替代该处皮肤。…     

四肢闭合性骨折合并血管损伤的诊治

本文就作者诊治的26例闭合性骨折合并血管损伤报告如下。1　临床资料本组26例中男23例,女3例;年龄8～43岁,平均26岁。骨折部位及血管损伤类型:锁骨骨折致锁骨下动脉部分破裂2例,肱骨髁上骨折致肱动脉痉挛2例、受压1例,股骨髁上骨折致动脉挫伤9例、部分破裂2例、痉挛1例,胫腓骨上段骨折致胫前动脉受压5例、挫伤4例。血管损伤的临床表现:4例血管破裂,骨折部迅速出现进行性增大的搏动性血肿,肢体剧痛、麻木,桡动脉或足背动脉搏动弱或消失,伤肢末端颜色苍白,毛细血管反应不良,血肿区可闻及与心率一致的搏动性杂音;肱动脉受压表现为骨折后尺桡…     

开放性胫腓骨骨折并软组织缺损32例报告

1994年5月至1997年1月,收治开放性胫腓骨骨折并软组织缺损32例,效果满意,报告如下。 1 临床资料 1.1 一般资料 本组32例,男21例,女11例。年龄19～61岁,车祸伤21例,压砸伤9例,热压伤1例,枪击伤1例。受伤至手术时间最短1.5h,最长12.5h。合并伤:颅脑损伤7例,气胸2例,腰椎骨折2例,股骨干骨折5例,尺桡骨骨折3例,骨盆骨折3例,尿道损伤1例,腘血管断裂2例,胫后动脉断裂3例,胫前动脉断裂2例。胫腓骨粉碎性骨折28例,螺旋骨折3例,横断骨折1例。软组织缺损最大37cm×14cm,最小4.5cm×3cm。均伴有胫骨外露,伴踝关节及伸趾肌腱外露8例。     

膝关节周围创伤伴腘窝血管伤的早期诊断与救治

目的 :探讨膝关节周围创伤伴腘窝血管伤的早期诊断与救治。方法 :回顾性分析2007年1月至2013年1月15例膝关节周围骨折、脱位伴腘窝血管损伤患者的临床资料,其中男9例,女6例;年龄26~62岁,平均39.2岁。结合临床症状、体征,运用血氧饱和度监测仪、彩色超声、DSA介入造影及手术探查等方法明确血管损伤,分别采用组合式外固定支架、钢板螺钉股骨髁逆行交锁钉内固定骨折及膝关节脱位,并根据具体情况对损伤血管进行取栓、修补、自体静脉移植重建血循环,分析手术时间、住院天数、保肢指数、输血量、医疗费用及感染发生情况,明确早期诊断及有效救治的作用。结果:本组患者死亡1例,截肢8例,6例手术成功修复腘动脉、胫前及胫后动脉。6例肢体存活患者随访12~60个月,平均28.3个月。保肢成功且关节功能优良4例。结论:膝关节周围创伤伴腘窝血管伤具有伤情复杂且严重、易误漏诊、预后差、保肢风险高等特点,应结合患者的创伤机制、损伤部位局部解剖特点、临床表现及适当的辅助检查来把握膝关节周围创伤伴腘窝血管伤的早期诊断,掌握合适的保肢与截肢指征以高效救治患者。     

55例踝关节外侧副韧带损伤合并外踝撕脱骨折的手术治疗分析

背景背景:踝关节外踝韧带损伤是最高发的踝关节损伤,目前针对外踝韧带损伤方面的研究较多,而对于外踝韧带损伤合并撕脱骨折的报道较少。目的:评价踝关节外侧副韧带损伤合并外踝撕脱骨折的临床特点及手术治疗效果。方法方法:2013年1月至2014年1月,55例踝关节外侧副韧带损伤合并外踝撕脱骨折患者接受了改良Brostrm法外踝韧带修复和撕脱骨块切除术。术前行X线片检查及MRI,术前及术后6个月随访时进行AOFAS踝-后足功能评分。结果结果:55例患者中51例于踝关节正、侧位X线片发现外踝撕脱骨折,其余4例通过MRI确诊。术前AOFAS评分为(54.62±10.31)分,术后6个月随访AOFAS评分平均为(87.70±3.22)分,与术前相比明显提高(P<0.05)。结论论:外踝撕脱骨折可以通过踝关节正、侧位X线片及MRI准确诊断。外踝韧带损伤伴外踝撕脱骨折应尽早进行治疗以防止慢性不稳发生。踝关节外侧副韧带损伤合并外踝撕脱骨折患者采用改良Brostrm法修复外踝韧带并切除撕脱骨块可得到良好的临床效果。     

Tibial shaft fracture and ankle joint injury

OBJECTIVE: Detection of tibial fractures in which a concomitant ankle injury may exist. DESIGN: Prospective study. SETTING: Department of Trauma Surgery, University Hospital. PATIENTS: 43 (20.1%) of 214 patients with a tibial fracture were found to have an associated injury of the ankle joint. INTERVENTION: Analysis of all patients with tibial fractures regarding typical mechanisms of injuries and typical radiographic criteria for concomitant injuries of the ankle joint. MAIN OUTCOME MEASURES: Primary x-rays were analyzed looking for spiral fractures of the tibia or proximal fibular fractures or an intact fibula, typically associated with syndesmotic injury. The assessment of patients was based on radiological findings and functional recovery. RESULTS: 45 ankle injuries in 43 patients were found. There were distal fibular fractures in 14, Maisonneuve fractures in 13, isolated ruptures of the syndesmosis in 3, fractures of the posterior malleolus in 8, and fractures of the medial malleolus in 7 of the cases. In 38 of the 43 patients, the distal tibiofibular syndesmosis was ruptured, and 88.4% of the tibia injuries were spiral fractures located in the distal third. Of the 38 patients who could be followed, 31 were categorized according to the Phillip's Score as very good, 3 as good, 2 as satisfactory, and 2 as unsatisfactory after an average of 19.8 months (12-26). CONCLUSION: Due to the obvious injury of the tibia, the potential instability of the ankle joint is often overlooked, and the risk of development of secondary osteoarthritis is often consequently underestimated. Added attention should be paid to the ankle in the following tibial fracture cases: pronation-eversion trauma, spiral fracture of the tibia, proximal fibular fracture, or intact fibula. Using these markers, we were able to diagnose 20.1% of combined injuries compared to our retrospective study in 1999, in which only 13.6% of these injuries could be detected (Pearson r=0.1305, not significant).     

Fracture of the tibia with additional injury of the ankle joint. A frequent and undervalued combination

Summary There are 2 types of a combined tibia fracture and ankle injury: in Type I the tibia fracture extends directly into the ankle joint, in Type II the tibia fracture goes along with a fracture of the fibula and disruption of the fibular-tibial syndesmosis. This type of fracture must be distinguished from a pilon tibiale fracture. The typical mechanism for this combined tibia and ankle injury is the indirect torsional trauma with pronation-eversion. From 1995 to 1997 188 patients with fractures of the tibia were treated by internal fixation in our Trauma Department. 27 of these patients (13.6 %) had a combined tibia and ankle injury. Most of the tibia fractures were located in the distal third, a spiral fracture (16 patients) or a comminuted fracture (6 patients), and another group extending directly into the ankle (5 patients). The ankle lesion was a distal fibular fracture (Weber Typ B + C) in 14 patients, a proximal fibular fracture (Type maisoneuve) in 6 patients, a postero-lateral fragment in 11 cases and a fracture of the medial melleolus in 10 cases. A disrupture of the anterior tibio-fibular syndesmosis was seen in 18 patients, 3 times as an isolated lesion of the ankle joint without fracture of the fibula. The osteosynthesis of the tibia fracture was performed with an unreamed tibia nail in 20 patients, with elastic-biologic plate fixation in 6 and with external fixation in 1 patient. The fibula fractures were stabilized by small fragment titaneum plates, the dorsolateral fragment and the medial malleolus were stabilized by lag-screws, the tibio-fibular ligament was sutured and, in a few cases only, held in place by a positioning screw. The outcome was controlled after 20,7 month according to the Phillip's Score (1996). We found not more than one pour results. It must be considered, that most of the combined injuries of the tibia and the ankle joint concerning 13,6 % of all tibia shaft fractures are usually not recognized and may result in an arthrosis of the ankle joint. The attention should be focused to the ankle joint in any spiral fractures of the distal tibia after indirect trauma, especially with a proximal fibular fracture or an intact fibula. Additional X-ray examination of the ankle joint is recommended during internal fixation of the tibia. Posttraumatic arthrosis of the ankle joint can be prevented by diagnosis and adequate anatomical reconstruction of the additional ankle joint injury.      

Fracture of the tibia with additional injury of the ankle joint. A frequent and undervalued combination Eine h?ufige, aber wenig beachtete Kombination

There are 2 types of a combined tibia fracture and ankle injury: in Type I the tibia fracture extends directly into the ankle joint, in Type II the tibia fracture goes along with a fracture of the fibula and disruption of the fibular-tibial syndesmosis. This type of fracture must be distinguished from a pilon tibiale fracture. The typical mechanism for this combined tibia and ankle injury is the indirect torsional trauma with pronation-eversion. From 1995 to 1997 188 patients with fractures of the tibia were treated by internal fixation in our Trauma Department. 27 of these patients (13.6 %) had a combined tibia and ankle injury. Most of the tibia fractures were located in the distal third, a spiral fracture (16 patients) or a comminuted fracture (6 patients), and another group extending directly into the ankle (5 patients). The ankle lesion was a distal fibular fracture (Weber Typ B + C) in 14 patients, a proximal fibular fracture (Type maisoneuve) in 6 patients, a postero-lateral fragment in 11 cases and a fracture of the medial melleolus in 10 cases. A disrupture of the anterior tibio-fibular syndesmosis was seen in 18 patients, 3 times as an isolated lesion of the ankle joint without fracture of the fibula. The osteosynthesis of the tibia fracture was performed with an unreamed tibia nail in 20 patients, with elastic-biologic plate fixation in 6 and with external fixation in 1 patient. The fibula fractures were stabilized by small fragment titaneum plates, the dorsolateral fragment and the medial malleolus were stabilized by lag-screws, the tibio-fibular ligament was sutured and, in a few cases only, held in place by a positioning screw. The outcome was controlled after 20,7 month according to the Phillip's Score (1996). We found not more than one pour results. It must be considered, that most of the combined injuries of the tibia and the ankle joint concerning 13,6 % of all tibia shaft fractures are usually not recognized and may result in an arthrosis of the ankle joint. The attention should be focused to the ankle joint in any spiral fractures of the distal tibia after indirect trauma, especially with a proximal fibular fracture or an intact fibula. Additional X-ray examination of the ankle joint is recommended during internal fixation of the tibia. Posttraumatic arthrosis of the ankle joint can be prevented by diagnosis and adequate anatomical reconstruction of the additional ankle joint injury.     

Examination of the pathologic anatomy of ankle fractures.

A prospective study of the translational and rotational displacement of the lateral malleolus in ankle fractures was carried out utilizing roentgenographic techniques. Twenty-six ankle fractures in 25 patients were studied using both routine plain films and CT scanning with two- and three-dimensional multiplanar reconstruction. Eighty-one percent were Lauge-Hansen supination-external rotation type injuries. Overall, 21 fractures did not involve the medial malleolus. Initial talar shift was less than or equal to 2 mm in 15 fractures. Although all patients exhibited external rotation deformities of the lateral malleolus on plain films, only one fracture was found to possess any degree of external rotation relative to the talus. The proximal fibula was seen on CT scans to have increased internal rotation with respect to the tibia in 19 cases. One patient had a slightly externally rotated proximal fibula; the remainder appeared normally aligned. The displacements measured by the CT scans at the talofibular articulation were compared with the standard plain film measurements. The displacements at the distal lateral malleolus were consistently overestimated by the plain roentgenograms, presumably because the capsular and ligamentous attachments to the distal fibula limit malleolar displacement. The talocrural angle, determined on both plain films and CT scans, was also not found to be a sensitive measure of fibular shortening nor of the severity of the fracture. The results of this study suggest that, in an isolated lateral malleolar ankle fracture, the apparent external rotation of the fracture fragment is relative only to the proximal fibula and is not associated with derangement of the talofibular articulation. Based on these mechanical considerations, surgical intervention for such fractures may not be necessary. This hypothesis is consistent with previous long-term clinical studies.     

Frakturen des oberen Sprunggelenks

Malleolar fractures predominately result from a dislocation force at the ankle and are usually accompanied by injuries of the collateral ligaments and the tibiofibular syndesmosis. Forced abduction, adduction or external rotation of the foot against the tibia produce the typical sequence of bony and ligamentous injuries at the ankle joint. With the foot in supination at the time of injury, the deforming force acts first on the lateral malleolus, with the foot in pronation the force acts first on the medial malleolus. Fracture-dislocations must be reduced as an emergency under sufficient analgesia. Early stabilization is generally preferable for all displaced and unstable ankle fractures. With operative treatment, exact reconstruction of the articular surface, restoration of the length and rotational alignment of the fibula and fixation of osseous or ligamentous syndesmotic injuries are important prognostic factors. Non-operative, functional treatment leads to good long-term results in isolated, non-displaced fractures of the medial or lateral malleolus provided that instability of the ankle mortise has been definitely ruled out. Treatment of pediatric and adolescent malleolar fractures follows the same principles and has to respect the growth plate which ossifies over an 18 month period. Special attention has to be paid to hereditary or acquired neuropathy with dramatically increased healing times and complication rates.     

后侧腓骨钢板内固定在踝关节骨折中的应用

目的：探讨踝关节骨折治疗的新方法并评价其疗效。方法：手术治疗踝关节骨折42例,对其中资料完整的34例进行分析,男19例,女15例。根据Weber-AO分类：B型28例,C型6例。应用Baird和Jackson评分系统对其术后疗效进行评定,并将骨折类型、骨折固定方法、术后功能锻炼时间与最终功能的关系进行分析。对34例Weber-AO分型的B型及C型踝关节骨折,采用腓骨后侧钢板内固定,以避免螺钉对关节面的损伤,对同时伴有后踝骨折的病例,同时一个切口对腓骨及后踝进行固定。结果：随访时间1.2～3.2年,平均1.8年。34例中疗效为优24例,良6例,可4例,优良率为88.2%。结论：腓骨后侧钢板内固定治疗踝关节骨折,避免了螺钉对关节面的损伤,增加了螺钉的把持力,并可一个切口同时完成外踝及后踝骨折的治疗,为踝关节骨折治疗提供了一个新方法。     

骨关节多发性创伤的流行病学分析

目的探讨多发性骨关节损伤的流行病学特点,以提高创伤的防治认识和救治质量,减少死亡率。方法总结2002年1月1日～2004年12月31日间救治的346例多发性骨关节损伤患者资料,按蔡氏法分类,统计分析患者性别、年龄、伤因、部位、数量、并发伤及死亡率。结果346例患者中,男278例,女68例；年龄9个月～89岁,平均32．8岁。致伤原因：交通伤226例,重物压砸伤65例,坠落伤及跌伤52例。胫、腓骨干骨折159处,股骨干骨折96处,尺、桡骨干骨折87处,踝足骨折58处,胸部伤57处,髋和膝部伤分别为50处,骨盆区损伤49例,腕手部伤46处,肩部伤36处,颅骨骨折36处,肱骨干骨折33处,脊柱骨折23处,肘部伤17处。2处伤者242例,3处伤83例,4处伤20例,6处伤1例,平均受伤部位2．3处。闭合伤205例,开放伤141例；合并颅脑伤51例,胸部伤23例,腹部伤5例,泌尿系损伤3例,休克78例,神经血管伤21例,脂肪栓塞6例。死亡5例。结论近年来,多发性骨关节损伤患者有增多趋势,且伤情较重,男性青壮年居多；交通伤是主要致伤原因；四肢多发伤以下肢伤为多,容易发现及确诊,而脑、胸、腹、盆部的闭合伤多易漏误诊治；近年来死亡率明显减少；加强急救创伤救治培训和安全教育,进一步提高医疗质量,可减少残废和死亡率。     

影响胫腓骨开放性骨折愈合的多因素分析

[目的]探讨影响胫腓骨开放性骨折愈合的主要因素。[方法]回顾性分析本院从2005年5月～2010年2月5年间收治的81例胫腓骨开放性骨折的病历资料。采用单因素分析患者年龄、性别、致伤原因、合并伤、骨折肢别、骨折分型、从受伤至开始清创的时间、固定方式、软组织修复时机、VSD的应用等10项因素与骨折愈合率的关系,对以上有意义的因素进行二分类的多因素Logistic回归分析。[结果]单因素分析结果,可能影响胫腓骨开放性骨折愈合的因素有致伤原因、骨折分型、从受伤至开始清创的时间及软组织修复时机等4个因素,多因素Lo-gistic回归分析发现致伤原因、骨折分型以及软组织修复时机与胫腓骨开放性骨折愈合独立相关,其他因素没有统计学意义。[结论]高能量损伤是影响胫腓骨开放性骨折愈合的危险因素,胫腓骨开放性骨折的愈合率与骨折分型严重程度有关,早期软组织修复有利于胫腓骨开放性骨折愈合。     

Incidence of Chondral and Osteochondral Lesions in Ankle Fracture Patients Identified With Ankle Arthroscopy Following Rotational Ankle Fracture: A Systematic Review

A systematic literature search was performed using the PubMed, MEDLINE, and the Cochrane Library databases according to the Preferred Reporting Items for Systematic review and Meta-Analyses guidelines on May 20, 2019. The keywords used were: ankle, distal tibia, distal fibula, fracture, arthroscopic, cartilage, and chondral. The objective of this study is to systematically review the characterization of intra-articular chondral injuries of the talus, tibial plafond, medial malleolus, and lateral malleolus in patients who undergo ankle arthroscopy following ankle fracture. Studies evaluating the incidence of chondral lesions at the time of arthroscopy for ankle fractures within any timeframe were included. The incidence of intra-articular chondral lesions was recorded, the location within the ankle, ankle fracture type, time of arthroscopy, characterization of chondral injury, complications, and outcome if available. Fifteen studies with 1355 ankle fractures were included. About 738 demonstrated evidence of chondral or osteochondral lesion (54.5%). Statistical analyses were carried out with statistical software package SPSS 24.0 (SPSS, Chicago, IL). We compared incidence rates of chondral injury based on Weber classification, malleolar fracture type, and Lauge-Hansen classification, using Pearson chi-square test. For all analyses, p < .05 was considered statistically significant. We found a high incidence of intra-articular chondral lesion in the setting of ankle fractures as demonstrated by arthroscopy.