牵拉骨骺损伤的临床探讨

牵拉骨骺损伤系指牵拉型骨骺在缺血性坏死的基础上又发生骨骺撕脱骨折的复合性疾患。它区别于过去大多数作者所描述的独立存在的骨骺炎或骨骺骨折。本文通过分析５例病例，对该病的损伤原因、发病机理、损伤病理、诊断与防治进行了探讨。     

钝性喉气管损伤的MSCT诊断

目的：探讨多层螺旋CT在钝性喉气管损伤（B-LTT）中的临床应用价值。方法：对喉颈部外伤后156例患者使用GE LightSpeed 16层及32层螺旋CT设备行CT检查,其中平扫111例和对比剂增强扫描45例,并通过最大密度投影（MIP）、多平面重组（MPR）、仿真内镜（VE）及容积再现（VR）等影像后处理技术进行喉软骨、喉部软组织三维成像。结果：共发现43例患者喉部损伤,包括软组织损伤28例,喉软骨骨折14例及舌骨骨折1例。喉软骨骨折14例中,甲状软骨骨折12例（右侧甲状软骨5例,左侧甲状软骨骨折3例,甲状软骨前部正中骨折4例）。同时合并环状软骨骨折3例,杓状软骨骨折2例,环杓关节脱位3例,环甲关节脱位2例,甲状腺损伤2例,皮下气肿12例,咽喉部血肿3例,颈2椎体骨折1例。MSCT显示喉软骨骨折的直接征象为喉软骨边缘不连续,可见低密度骨折线影,也可伴移位。软组织损伤表现为声门及气道狭窄,伴咽喉部血肿、皮下气肿。喉周围软组织内出现气泡是喉黏膜撕裂的间接征象。结论：螺旋CT可多方位显示喉软骨骨折部位、程度以及气道狭窄和喉黏膜撕裂情况,是诊断喉损伤快速有效的方法。     

青少年急性膝关节软骨损伤的MRI表现

目的 分析青少年急性膝关节软骨损伤的MRI表现.方法 回顾性分析53例(年龄4~27岁)在1个月内有膝关节损伤病史,且经关节镜手术证实的急性膝关节软骨损伤的MRI表现,重点观察软骨、软骨下低信号线和软骨下骨髓的改变.结果 MRI共发现69处软骨损伤,其中髌骨25处,股骨外髁22处,股骨内髁11处,股骨滑车2处,胫骨平台9处.单纯软骨骨折46处,包括软骨全层断裂22处、软骨部分断裂20处及裂隙状软骨骨折4处.骨软骨骨折23处,包括骨软骨撕脱骨折13处和软骨下骨质内陷10处.关节内软骨性游离体6例,骨软骨游离体13例.结论 MRI是急性软骨损伤最好的无创性检查方法.     

Comparison of CT and MRI in patients with tibial plateau fracture: can CT findings predict ligament tear or meniscal injury?

Objective (1) To determine the accuracy of computed tomography (CT) in the evaluation of ligament tear and avulsion in patients with tibial plateau fracture. (2) To evaluate whether the presence or severity of fracture gap and articular depression can predict meniscal injury. Design and patients A fellowship-trained musculoskeletal radiologist retrospectively reviewed knee CT and MRI examinations of 41 consecutive patients presenting to a level 1 trauma center with tibial plateau fractures. Fracture gap, articular depression, ligament tear and footprint avulsions were assessed on CT examinations. The MRI studies were examined for osseous and soft tissue injuries, including meniscal tear, meniscal displacement, ligament tear, and ligament avulsion. Results CT demonstrated torn ligaments with 80% sensitivity and 98% specificity. Only 2% of ligaments deemed intact on careful CT evaluation had partial or complete tears on MRI. Although the degree of fracture gap and articular depression was significantly greater in patients with meniscal injury compared with those without meniscal injury, ROC analysis demonstrated no clear threshold for gap or depression that yielded a combination of high sensitivity and specificity. Conclusions In the acute setting, CT offers high sensitivity and specificity for depicting osseous avulsions, as well as high negative predictive value for excluding ligament injury. However, MRI remains necessary for the preoperative detection of meniscal injury.     

The use of computed tomography in determining developmental changes, anomalies, and trauma of the thyroid cartilage

Recognition of injury to the hyoid bone and thyroid and cricoid cartilages is intrinsic to post-mortem examination. Due to its increasing brittleness with age the thyroid cartilage is particularly susceptible to injury following neck trauma, although there is inconsistency in the patterns of injury reported. In this study computed tomography scans of the head and neck of 431 deceased persons (235 males and 196 females) between the ages of 1 day and 100 years (mean age 35.93 ± 24.15), and including 25 victims of hangings, were examined to reveal the pattern of age-related change and the types of injury that occurred. Thyroid cartilage anomalies likely to cause confusion and be misinterpreted as trauma-related are documented. Angulation of the thyroid cartilage horns was found to change with age, and it is suggested this may be a significant factor in traumatic neck injury. Unlike in previous reports, the average age of hanging victims with fractures to the thyroid cartilage was 34 years. The base of the superior horn was the most common fracture site and in 50 % of hanging cases was associated with a ligature positioned on the thyrohyoid membrane or thyroid lamina. Although an age-related relationship exists it was not possible to establish narrow age-prediction ranges from calcification of the thyroid cartilage.     

Rehabilitation of avulsion fracture of the tibial tuberosity following Osgood-Schlatter disease

A sixteen-year-old boy suffered from sharp pain in the knee during a jump while playing basketball. He had a positive history of Osgood Schlatter disease. Radiographic evaluation demonstrated an avulsion fracture of the tibial tuberosity Type III according to the classification of Watson-Jones. Rehabilitation after avulsion fracture of the tibial tuberosity is an important consideration for this relatively uncommon adolescent injury. In such avulsion fractures, landing on the ground with the knee fully extended after a jump is the most likely cause. This case report reviews the rehabilitation program, and selected functional outcome measures after rehabilitation are reported. The patient returned to sporting activity after 12 months.     

Stress fracture in combination with avulsion from the tibia in a marathon runner: a case report

We report an exceptional case of a tibial stress fracture combined with a large avulsion from the posterior facet of the tibia at the level where the tibialis posterior and soleus muscles insert. This type of injury has not been reported previously. A young healthy male runner experienced a sudden “snap” in the right lower leg 25 km into a marathon and had to leave the race due to increasing pain. The fracture was immediately apparent on plain radiographs. The injury was treated conservatively with 9 weeks in an ROM knee cast and no weight bearing on the affected leg, followed by full recovery. We propose that prolonged muscle tension at the site of tendinous attachment to the bone can cause the development of a stress fracture type of avulsion.     

多层螺旋CT三维成像在急性肋骨骨折诊断中的应用

目的:探讨多层螺旋CT三维重组在急性肋骨骨折诊断中的价值。方法:利用GE Lightspeed 16多层螺旋CT机对胸部外伤患者在外伤后10d内进行多层螺旋CT肋骨扫描,并进行薄层重建,于工作站上进行VR、MIP三维图像重组,由2位医师对后处理图像进行观察,并与肋骨平片结果对照分析。结果:66例中总肋骨骨折数为200根,CT横断图像直接显示骨折线63例198根,检出率99%。三维容积重组图像显示骨折197根,检出率98.5%。其中2根三维重组图像显示而横断面图像未能显示,3根横断面显示而三维图像未能显示。肋软骨骨折1例1根。平片诊断骨折152根,检出率76%;可疑骨折6例12根,CT确诊10根,排除2例;平片未见骨折5例,CT扫描发现10根骨折;另有4例确诊10根,可疑5根,CT确诊16根骨折,排除3根骨折。结论:多层螺旋CT三维成像对肋骨骨折的检出率、诊断符合率明显高于普通肋骨平片,结合横断面CT图像可准确定位,发现合并症,是胸部外伤后常规肋骨平片的重要补充检查。     

Extension corner avulsion fracture of the cervical spine

The purpose of this study was to determine the radiographic findings and clinical significance of the extension corner avulsion fracture (ECAF) of the cervical spine and to defined the role of the plain radiography, computed tomography (CT), and magnetic resonance imaging (MRI) in the evaluation of this injury in order to establish a radiographic protocol. Imaging studies of the cervical spine (including plain radiographs, CT scans, and MRI examinations) and medical records of 31 patients from two major trauma centers were reviewed retrospectively. Twentyeight (90%) of 33 ECAFs occurred at C2. Two patients (7%) had ECAF at more than one level. Ten patients (32%) had additional cervical injuries. Traumatic spondylolisthesis of C2 was the most common associated cervical injury (10%). Seven patients (23%) had associated thoracolumbar injuries. Although all available sagittal reformations demonstrated characteristic fracture, axial CT images failed to demonstrate the fracture in three cases, but, in one patient, they revealed other clinically insignificant fractures not appreciated on plain radiographs. MRI was noncontributory in cases of isolated ECAF. Five patients (16%) had neurologic deficits, with three localized to the cervical region. ECAF occurs most commonly at C2, typically does not result in direct neurologic injury, and is characterized radiographically by a triangular-shaped anteroinferior corner fracture fragment with associated soft tissue swelling. In most cases, ECAF can be adequately assessed by plain radiography. CT and MRI should be reserved for patients with complex fracture patterns or neurologic symptoms.     

Medial patellofemoral ligament avulsion injury at the patella: classification and clinical outcome

Purpose

To define medial patellofemoral ligament (MPFL) injury characteristics at the patellar attachment and clinical outcome in patients with primary traumatic patellar dislocation and MPFL avulsion injury at the patella.

Methods

Magnetic resonance imaging (MRI) was used to assess patients with primary (first-time) patellar dislocation and MPFL injury at the medial margin of the patella. Fifty-six patients with patellar attachment MPFL injury were enrolled in the study. Thirteen patients underwent surgical fixation of the avulsed MPFL and patellar medial margin osteochondral fracture, and the remaining patellar MPFL injures were treated nonoperatively. Forty-four patients were evaluated clinically at median four (range 1–10) years after patellar dislocation. The follow-up included evaluation of recurrent patellar instability, subjective symptoms, and functional limitations.

Results

Three types of patellar MPFL injuries were found; type P₀ with ligamentous disruption at the patellar attachment, type P₁ with bony avulsion fracture from the medial margin of the patella, and type P₂ with bony avulsion involving articular cartilage from the medial facet of the patella. Of the patellar MPFL avulsion injuries that underwent initial surgical fixation, two patients (2/13) reported an unstable patella at follow-up. Fifty-five per cent (17/31) of patellar MPFL avulsion injuries that were treated nonoperatively had recurrent patellar instability (n.s.). The median Kujala score was 90 for patellar avulsion with surgical fixation and 86 for patellar avulsion without surgical fixation (n.s.).

Conclusion

Patellar attachment MPFL injury showed three different patterns, classified as types P₀, P₁, and P₂. MRI can be used to assess the injury pattern. Patellar MPFL avulsion injuries do not benefit from acute surgical repair compared with nonsurgical treatment. Type P₂ patellar MPFL avulsion includes an osteochondral fracture that may require surgical fixation.

Level of evidence

Prognostic study, Level III.     

轻中型颅脑损伤合并无脊髓损伤的上颈椎骨折脱位的诊治

目的总结轻中型颅脑损伤合并无脊髓损伤的上颈椎骨折脱位的诊治经验,以提高对其的认识和疗效。方法回顾性分析2012年1月—2017年12月海军军医大学附属公利医院骨科收治的25例轻中型颅脑损伤合并无脊髓损伤的上颈椎骨折脱位患者临床资料,男性14例,女性11例;年龄20~71岁,平均48.2岁。颅脑损伤9例行手术治疗,16例行非手术治疗;颈椎骨折10例行非手术治疗,13例单独行颈椎手术,2例一期颅颈联合手术。出院时进行格拉斯哥预后评分(GOS评分),术后门诊随访X线片或CT片评价颈椎骨折愈合情况。结果出院时GOS V级20例,IV级4例,I级1例。随访12~48个月,平均24.5个月,复查颈椎X线片或CT示骨折愈合良好。结论颅脑损伤患者常规颈椎CT扫描有助于上颈椎损伤的早期诊断。上颈椎不稳定骨折在病情允许下尽早手术,可减少并发症的发生。     

螺旋扫描三维CT在颌面部骨折诊治中的应用

目的探讨螺旋三维CT在颌面部骨折的诊断及指导手术治疗方案中的临床价值。方法对58例患者术前、术后均以螺旋CT于颌面部骨折部位行薄层连续扫描,应用三维表面重建处理软件,重建颌面部骨折的三维影像,图像旋转获得最佳图像照片,并做分析。结果58例患者中49例采取了手术治疗,3例髁状突骨折无明显移位的病例采取了非手术治疗,所有手术病例都证实了术前三维CT的诊断,术后三维CT显示所有手术部位均获得了解剖复位,手术效果满意。结论通过应用三维成像技术可获得颌面部骨及骨折的高清晰的三维影像,为颌面部骨折的诊断、治疗及疗效评估提供参考,特别是面中份及髁状突部位的骨折,以及颌面部多发性骨折、创伤后的复杂畸形的检查,三维CT具有独特的价值。     

3D打印模型与CT三维重建影像辅助手术治疗复杂髋臼骨折的疗效

目的 探讨使用骨折3D打印模型辅助手术与参考骨折处CT 三维重建影像辅助手术治疗复杂髋臼骨折的疗效.方法 回顾性分析2017年10月-2020年9月汉中市中心医院骨关节外科手术治疗复杂髋臼骨折患者60例,男性36例,女性24例;年龄25～64岁,平均41.8岁.根据是否使用3D打印模型分为3D组(34例)及对照组(26...     

Avulsion fractures in athletes.

34 cases of avulsion fractures are described. Each fracture took place during athletic training or competition. Excepting six sportsmen participating in a general fitness programme, every patient was an active competitive athlete. There were six women and 28 men; their average age was 20.1 years, raised by a few middle-aged "fitness sportsmen". Most avulsion fractures took place in sprinters and hurdlers; next were middle and long distance renner, footballers, fitness joggers, skiers and ice-hockey players. The most usual location of a fracture was the anterior pelvic spines; avulsion fractures were also detected in various parts of lower limbs. There were fewer avulsion fractures in the area of the trunk and upper extremities. Roetgenologically, the diagnosis of an avulsion fracture is generally easy to make. However, the diagnosis is facilitated by knowing the mechanism of the injury, the technique of the athletic event, and some of the training methods. Generally, a fracture heals well, even if it requires both sufficient immobilisation and some delay in resuming physical exertion.     

闭合性喉损伤的CT诊断

目的 搪塞闭合性喉损伤的ＣＴ表现及诊断价值。方法 对１６例闭合性喉损伤病人的ＣＴ和临床资料进行回顾性分析。结果 软组织损伤５例,杓会厌襞和真假声带肿胀、气道狭窄４例,左环杓关节脱位,声带麻痹１例;声门损伤２例;均有会咽软骨骨折伴榴府厌襞和下咽部撕裂;声门损伤４例;甲状软骨右翼部骨折１例,甲状软骨前联合部纵行或粉碎骨折３例,其中１例骨折片进入喉腔形成异物,两侧声带和前联合撕脱;声门下损伤（５例）：左     

Horizontal fracture of the anterior arch of the atlas associated with a congenital cleft of the anterior arch

We report a rare combination of a horizontal fracture of the anterior arch of the atlas associated with a congenital cleft of the anterior arch. Sagittally reformatted computed tomography (CT) images demonstrated a fracture of the anterior arch of the atlas and a type II odontoid process fracture. There was also a smoothly marginated midline cleft of the anterior arch just above the fracture consistent with a congenital variant. 3D CT images were helpful in the evaluation of the fractures and the developmental variant. Magnetic resonance imaging showed a spinal cord injury. The patient underwent posterior C1–C2 fusion.     

An <Emphasis Type="Italic">en bloc</Emphasis> avulsion fracture of tibial tuberosity and Gerdy’s tubercle in an adolescent basketball player: a case report

We report a case of en bloc avulsion fracture of tibial tuberosity and Gerdy’s tubercle, which has never been reported. A 14-year-old boy suffered from an acute pain in his left knee during running just before a jump. Simple radiographs showed an avulsion of the tibial tuberosity. On CT scans, the fractured fragment was attached not only to patellar tendon but also to iliotibial band (ITB) via Gerdy’s tubercle. MRI evaluation revealed no intra-articular associated pathology. Open reduction and internal fixation with three cannulated screws were performed under lateral parapatellar approach to expose both the tibial tuberosity with patellar tendon and Gerdy’s tubercle with ITB. At postoperative 1 year, he could walk, run, squat, and complained of no difficulty in activities on daily living with full range-of-motion of the knee. Radiographs showed well-healed fracture in situ. Gradually, he returned to sports activity. We believe that the injury was caused by the dynamic pull of quadriceps muscle via patellar tendon onto tibial tuberosity and the mostly static pull of ITB onto Gerdy’s tubercle, both of which took a part in the fracture of the anterolateral portion of the unfused epiphysis of proximal tibia. The pes anserinus attaching on the anteromedial metaphysis of proximal tibia might exert the opposing deforming force. Preoperative planning including the determination of the extent of fracture and recognition of concomitant injury is a prerequisite for appropriate treatment.     

踝关节后方隐匿性小片骨软骨撕脱骨折的临床诊治

目的 探讨踝关节后方隐匿性小片骨软骨撕脱骨折的发生机理、发病特点及治疗方法.方法 对我院在2009年10月～2010年10月收治的5例踝关节后方隐匿性小片骨软骨撕脱骨折患者的临床诊疗资料进行回顾性分析.结果 本组5例患者的临床症状全部于术后消失,术后1 w开始下地行走,出院后进行为期6个月～2年的随访,均未复发.结论 踝关节后方隐匿性小片骨软骨撕脱骨折的早期临床表现特异性较低,X线平片及CT检查中的表现也较为隐匿,容易造成漏诊,应引起重视.目前对于该病保守治疗效果不明显,应进行手术治疗,治愈率及症状改善程度均较高.     

CT三维重建在骨盆骨折及盆腔脏器损伤手术治疗方案设计中的价值

目的：探讨螺旋CT三维重建在骨盆骨折及盆腔脏器损伤手术治疗方案设计中的价值。方法分析2007年1月至2013年12月行手术治疗的骨盆骨折及盆腔脏器损伤的患者CT三维重建影像资料,比较术前与术后影像资料及疗效。采用SPSS 17．0统计软件和χ2检验分析轴位CT及三维CT对骨盆骨折诊断的差异。结果149例骨盆骨折患者通过CT三维重建确诊髂骨骨折19例、骶尾骨骨折43例、耻骨上下支骨折30例及髋臼骨折57例;关节脱位21例、耻骨联合分离5例。轴位CT组与三维CT组间比较在髋臼骨折及骶尾骨骨折上,差异有统计学意义（P＜0．05）。髂骨骨折、耻骨上下支骨折、关节脱位及耻骨联合分离无统计学意义。合并盆腔脏器损伤有17例,其中膀胱破裂8例、后尿道损伤5例,盆腔血肿4例。149例患者术后复位效果中解剖复位64例,满意75例,不满意14例。获得随访20 d至83个月。按Matta疗效标准评定,临床标准：优97例,良45例,可7例,优良率95％;X线标准：优95例,良45例,可9例,优良率94％。结论螺旋CT三维成像多平面重建（MPR）、容积重建（VR）及表面遮盖重建（SSD）以最直观、全面的骨盆骨折及盆腔脏器损伤图像肯定并明确螺旋CT对骨盆骨折的分型;对治疗方案、手术入路、内固定物的选择和制定详细的手术计划可提供正确指导,在骨盆骨折及盆腔脏器损伤术前、术后影像检查中有较高的价值。     

Lauge-Hansen旋前外展Ⅲ度踝骨折特点及下胫腓联合复位情况分析

目的探讨Lauge-Hansen旋前外展III度踝骨折(PA-Ⅲ度踝骨折)特点和下胫腓联合(ITFS)复位质量。方法回顾性分析2015年4月—2016年10月天津医院足踝外科入院诊断为PA-Ⅲ踝骨折患者52例,男性44例,女性8例;年龄15~74岁,平均37.7岁;右踝18例,左踝34例。由1名主治医师阅读伤后踝X线片并作出诊断,主任医师联合三维CT观察踝骨折特点修正诊断,对比分析误诊组和确诊组内踝骨折、Tillaux结节骨折及下胫腓联合分离、外踝骨折部位、类型、主要骨折线方向和主要骨折块位置。术后X线及CT确定ITFS复位质量,间隙与胫距间隙差值>2mm确定为复位不良。结果52例患者根据伤后X线检查确诊为PA-Ⅲ度踝骨折,三维CT分析踝骨折特点后证实21例误诊,误诊率40.38%。两组在内踝骨折、外踝骨折、Tillaux结节骨折及下胫腓联合分离比较差异无统计学意义(P>0.05);两组在外踝骨折类型、主要骨折线方向、主要骨折块位置比较差异有统计学意义(P<0.05),在外踝骨折平面比较差异无统计学意义(P>0.05)。确诊组患者中术后ITFS复位不良7例(22.6%)。结论单纯依靠X线片诊断PA-Ⅲ度踝骨折误诊率较高,CT三维重建观察外踝骨折类型、主要骨折线方向和骨折块位置可辅助确诊。PA-Ⅲ度踝骨折术后ITFS复位不良发生率较高。