CT三维重建技术在髋臼骨折诊断中的应用价值

目的探讨CT三维重建技术在髋臼骨折诊断中的应用效果。方法将本院收治的46例髋臼骨折患者分为X线片组、CT平扫组和CT三维重建组,对三组髋臼骨折检出率、骨折分型正确率、骨折移位情况判断正确率进行比较。结果 X线片组、CT平扫组、CT三维重建组的髋臼骨折检出率依次为58.70%、80.43%、100%,髋臼骨折分型正确率依次为39.13%、73.91%、100%,对骨折移位情况判断的正确率依次为47.83%、76.09%、100%,即CT三维重建技术对髋臼骨折检出、髋臼骨折分型、髋臼骨折移位情况判断的诊断价值明显优于X线片和CT平扫(P0.05)。结论 CT三维重建技术可以帮助医生直观地观察髋臼骨折情况,对骨折分型及制定手术方案具有较大补益。     

螺旋CT三维重建在肱骨近端移位骨折分型及治疗中的应用

目的 探讨螺旋CT三维重建对肱骨近端移位骨折分型的影响及在肱骨近端移位骨折中的临床应用价值。方法 收集经手术治疗的肱骨近端移位骨折20例，所有患者术前均接受X线片检查，同时行肩部螺旋CT扫描和三维重建。根据Neer分型法对骨折进行分型，比较X线片和螺旋CT三维重建两种方法对肱骨近端移位骨折分型诊断的正确率，并评价螺旋CT三维重建在肱骨近端移位骨折治疗中的作用。结果 经手术证实：20例中Neer二部分骨折4例、三部分骨折9例、四部分骨折7例，普通X线片对肱骨近端移位骨折分型诊断的正确率为55％(11／22)，螺旋CT SSD、MPR结合二维CT横切面图像对肱骨近端移位骨折分型诊断的正确率为90％(18／20)，两者比较有显著差异(P＜0．05)，所有螺旋CT三维重建资料均对治疗具有指导作用。结论 对有手术适应证者，术前行螺旋CT三维重建对肱骨近端移位骨折分型及决定治疗方案有重要的指导价值。     

三维CT重建在髋臼骨折诊断与治疗中的应用

髋臼骨折是一种较常见的骨折，且是累及关节面的骨折，以往根据X线片对其进行诊断、分型和手术，但髋关节是一个复杂的结构，特别是发生严重骨折后，正常的对位关系完全消失，X线片甚至是CT扫描很难使医生全面客观的了解骨折和移位程度，影响骨折分型和手术方案的确定，甚至漏诊、误诊。本院从1999年采用CT三维重建诊治髋臼骨折9例，并对其临床优点进行了探讨。     

髋臼骨折术后残留移位与髋关节功能的相关性分析

目的通过术后CT评价髋臼骨折复位质量,探讨累及负重区和非负重区的残留移位(台阶移位和间隙移位)与术后髋关节功能的相关性。方法回顾分析2004年6月-2009年6月48例髋臼骨折患者术后CT检查和临床随访结果。患者均行切开复位内固定。术后均获随访,随访时间24～72个月,平均36个月;骨折均愈合。根据关节面残留移位是否累及负重顶,将患者分为负重区组(30例)和非负重区组(18例)。髋关节功能按Merled’Aubigné-Postel标准评定;术后关节面复位质量采用CT评价,于CT片上测量残留移位的两个指标(台阶移位和间隙移位)最大值。所得数据均采用Spearman秩相关检验分析。结果负重区组残留移位值与髋关节功能成强负相关性(rs=—0.722,P=0.001);非负重区组残留移位值与髋关节功能无相关性(rs=0.481,P=0.059)。临床随访结果与相关性分析一致。负重区组台阶移位值与髋关节功能成极强负相关(rs=—0.825,P=0.002),而间隙移位值与髋关节功能无相关性(rs=0.577,P=0.134)。结论髋臼骨折患者术后髋关节功能不仅与关节面残留移位大小相关,还与残留移位部位相关。与非负重区相比,累及负重区的残留移位是影响术后髋关节功能的关键因素;在负重区台阶移位值越大,髋关节功能越差。     

髋臼移位骨折手术治疗的疗效分析

为了解影响新鲜髋臼移位骨折切开复位程度及临床疗效的有关因素,该文作者从临床及影像学表现方面进行了回顾性分析。手术指征为骨折移位5mm,伴有髋关节不稳定、关节面对合不良,骨折块压缩嵌插。411例病人424侧髋臼骨折中,119侧为单纯髋臼骨折,305侧合并其他损伤,平均手术时间为伤后8.2天(0～21天)。病人平均年龄为46.5岁(13～89岁)。术前对骨盆摄前后位片和两个45°斜位片,CT扫描和三维重建。骨折块移位平均23.3mm(5～62mm)。针对不同时期和骨折类型,分别采用不同的固定方法,很多病人采用钻头、克氏针或钢索作暂时的固定,399侧髋(94％)用钢板和螺钉作可靠的固定,包括1982年后应用的重建钢板及1986年后应用的钩钢板和钢索。对单纯横行骨折、T型骨折或伴有一较大密质骨块的髋臼后壁骨折,采用松质骨螺钉固定。424侧髋中,获解剖复位(移位0～1mm)282侧(67％),复位     

移位髋臼骨折的手术治疗

目的探讨手术治疗移位髋臼骨折的最佳时机、入路选择、复位方法与技巧,以提高髋臼骨折的诊疗水平。方法对38例移位髋臼骨折术前大部分行CT图像三维重建,确定骨折类型并制定手术方案,选择最佳手术入路进行骨折复位,用骨盆重建钢板或螺丝钉固定。结果36例获得6个月～3年,平均14个月的随访。按M atta疗效评定标准评定,优28例,良4例,可4例,优良率88.9%。并发症主要有坐骨神经损伤、髋关节黏连和异位骨化。结论CT图像三维重建对判断髋臼骨折的部位、移位方向和损伤程度有重要意义,对手术入路选择和手术复位固定有指导作用。对移位髋臼骨折的治疗应该采取积极的态度,只要骨折移位大于3 mm都应切开复位内固定,术前正确判断骨折类型,选择最佳入路,术中准确复位和妥善固定是提高髋臼骨折疗效的关键。     

复杂髋臼骨折术中应用CT扫描的意义

 目的 探讨复杂髋臼骨折术中应用CT扫描的意义。方法 2008年 6月至 2010年 12月, 结合术中 CT监测治疗复杂髋臼骨折患者 14例, 男 9例, 女 5例;年龄 28~62岁, 平均 45.1岁。根据 Le tournel分型: 后柱加后壁骨折 2例, 横行加后壁骨折 4例, 野T冶形骨折 2例, 前柱加后半横行骨折 3例, 双柱骨折 3例。其中合并髋关节后脱位 3例, 股骨骨折 2例, 跟骨骨折 1例, L1骨折 1例, 坐骨神经损伤1例, 颅脑损伤 1例。术前采用 X线片、CT三维重建对骨折进行评估, 并使用三维影像处理软件进行术 前计划。手术复位后临时固定, 并使用野C冶型臂 X线机和 CT扫描三维重建评估复位质量, 对复位不满意 者重新复位。再次行术中 CT扫描三维重建检查内固定位置, 并与术前计划对照。结果 14例患者术中 平均接受 CT扫描 2.7次, 手术时间平均为 40.4 min, 平均接受放射量约为 47.2 mGy。术中再行复位者 4 例, 更改术前计划者 1例。术后采用 Matta影像学评价标准进行评估, 优 8例, 良 3例, 差 3例;优良率为 78.6%。结论 术中 CT扫描三维影像监测增加了手术时间和患者放射线暴露, 在评估复位质量方面与 传统野C冶型臂 X线机相似, 根据术中 CT扫描三维重建结合术中情况实施手术与术前计划基本吻合。在 术前使用 X线片、CT三维重建对髋臼骨折进行仔细评估的前提下, 术中使用 CT三维影像监测是否有 利于提高手术成功率减少手术并发症尚有待进一步商榷。     

隐匿性髋臼骨折一例漏诊的经验教训

笔者于2006年11月,收治了1例外院漏诊的隐匿性髋臼骨折,报告如下. 1病例报告 患者,男,49岁,因"车祸致全身多处疼痛、活动受限21 d"入院.当地医院摄X线片示右锁骨骨折、右胫骨近端骨折,摄骨盆X线平片未见有明显的髋部骨折征象,予行右锁骨骨折、右胫骨近端骨折切开复位.出院后仍感右髋部疼痛,其他医院CT扫描示右髋臼骨折(横行加后壁骨折).笔者收治后,予股骨髁上骨牵引,全身麻醉下行右髋臼骨折切开复位内固定术,术中显示右髋臼骨折前柱骨折断端有较多纤维骨痂生长,后柱、后壁移位明显,后壁骨折块有压缩伴骨缺损,予以行内固定并行后壁骨缺损植骨治疗.     

手术治疗移位髋臼骨折31例

目的探讨移位髋臼骨折的手术方法和疗效。方法回顾分析2003年5月至2009年7月在我院治疗的31例移位髋臼骨折,按Letournel分类方法而采用不同手术入路使用重建钢板及螺钉内固定治疗后壁骨折6例,后柱骨折4例,前壁骨折2例,前柱骨折3例,横行骨折6例,横行伴后壁骨折3例,双柱骨折2例,后壁伴后柱骨折3例,T型骨折2例。结果所有病例获3-36个月随访,按美国矫形外科评价髋关节功能的方法进行评价,优20例,良6例,可3例,差2例,优良率为83.8%。结论术前结合X线CT正确判断髋臼骨折类型,选择合适的手术入路,使骨折复位精确,结合重建钢板和螺钉固定,可获得良好的治疗效果。     

髋臼合并同侧股骨颈骨折的手术治疗与预后

目的 探讨髋臼合并同侧股骨颈骨折的手术方法与预后.方法 1990年10月至2008年1月共收治7例髋臼合并同侧股骨颈骨折患者,其中男5例,女2例;年龄22～55岁(平均38.6岁).髋臼骨折按Letournel分类:后壁骨折2例,后柱伴后壁骨折1例,横行伴后壁骨折2例,双柱骨折2例.股骨颈骨折按Garden分型:Ⅲ型2例,Ⅳ型5例.其中X线片和CT片示股骨颈骨折合并股骨头游离脱位于髋臼后上方者5例,仅显示股骨颈骨折而无脱位者2例.结果切开复位内固定术后X线片示5例移位髋臼骨折患者获解剖复位,2例获满意复位.股骨颈骨折均获满意复位和固定.7例患者术后获1～18年(平均8.6年)随访,X线片示5例合并股骨头脱位者日后均出现股骨头缺血性坏死,坏死率高达100%(5/5),髋关节功能恢复均为差,于内固定术后2～4年改行全髋关节置换术.而2例股骨头未脱位者至今X线片上仍未显示任何股骨头坏死迹象,也无创伤后关节炎表现,髋关节功能恢复均为优.结论 髋臼合并同侧股骨颈骨折患者,如同时合并股骨头脱位,因股骨头坏死率高,应首选全髋关节置换术治疗.如未合并股骨头脱位,可以考虑首选切开复位内固定.     

Assessment of articular fragment displacement in acetabular fractures: a comparison of computerized tomography and plain radiographs

OBJECTIVES: Quantitatively evaluate plain radiographs, relative to computed tomography (CT) scans, for assessment of articular fragment displacement (step and gap) in displaced acetabular fractures and in canine osteotomized acetabular specimens. DESIGN: Retrospective evaluation of a consecutive series of CT scans and plain radiographs of patients with displaced acetabular fractures and canine acetabulae osteotomized to represent acetabular fractures with displacement. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Computed tomography scans and plain radiographic images of 62 consecutive patients with displaced acetabular fractures were reviewed; 20 patients met the inclusion criteria regarding location, fracture pattern, availability of plain radiographs and CT scans, and the position of the femoral head at the time of radiographic assessment. The hemipelvi of five adult mongrels underwent osteotomy of the acetabulum and similar radiographic evaluation. INTERVENTION: Three independent reviewers measured step and gap deformity on plain radiographs and CT scans utilizing a standardized measurement technique. MAIN OUTCOME MEASUREMENTS: Sensitivity and specificity of plain radiographs for detecting step and gap displacement (2 mm and 4 mm) relative to CT scans were determined. Intraclass correlation coefficient and intraobserver reliability was also calculated. For the canine specimens, sensitivities of each imaging method were determined relative to actual fragment displacement measurements. RESULTS: In the clinical images, when compared to CT, plain radiographs showed poor sensitivity at detecting step deformity (sensitivity = 25%). When analyzed by fracture type, plain radiographs were particularly poor at detecting step deformities in fractures involving a single column of the acetabulum (sensitivity = 0%). Excellent intraobserver and intraclass reliability existed among the three reviewers. Computed tomography scans were considerably more accurate in measuring step and gap displacement relative to actual measurements than plain radiographs in the canine specimens. CONCLUSIONS: 1) Plain radiographs showed poor sensitivity for the detection of step and gap deformities in patients with acetabular fractures and in osteotomized canine specimens, relative to CT scans; 2) differences between CT and plain radiographs in both specimen types were greatest with the most clinically relevant deformity-i.e., step; and 3) CT scans are essential and should continue to be used in conjunction with plain radiographs in the preoperative evaluation of displaced acetabular fractures and perhaps should be considered in the postoperative assessment of fracture reduction.     

Postoperative radiographic assessment of acetabular fractures: a comparison of plain radiographs and CT scans

OBJECTIVES: This investigation was designed to compare computerized tomography (CT) and plain radiography for detection of articular step and gap deformity after healing of operatively treated acetabular fractures. DESIGN: Retrospective review of CT and plain radiographic images of 15 patients treated operatively for a displaced acetabular fracture. SETTING: Level I trauma center. MAIN OUTCOME MEASURES: Ability of CT scans and plain radiographs to detect residual articular steps and gaps after healing of acetabular fractures managed by open reduction and internal fixation. RESULTS: Using standardized evaluation techniques, more patients were found to have residual articular incongruities on CT scans (8 with step and 7 with gap) than on plain radiographs (1 with step and 6 with gap). In addition, a step deformity on CT scan correlated with a gap deformity, and as the size of the step deformity increased, so too did the size of the gap deformity. CONCLUSIONS: Based on our data, computerized tomography is more likely than plain radiographs to allow detection of residual articular incongruities in healed acetabular fractures. The authors believe that CT scans improve the evaluation of articular reduction and that this information can be used to further evaluate surgical technique and provide insight as to the impact of residual articular incongruity on the development of hip arthrosis.     

The usefulness of computed tomography following open reduction and internal fixation of acetabular fractures

PURPOSE: To investigate the role of a supplemental imaging modality in postoperative assessment of acetabular fractures following open reduction and internal fixation. METHODS: Postoperative axial computed tomographic (CT) scans were compared with plain radiographs of 20 patients with regard to their sensitivity for detecting articular fracture reduction in terms of gap displacement and step deformity or offset. Three observers independently reviewed the plain radiographs and CT scans at 2 separate time points and categorised the outcome as either anatomical or non-anatomical. The inter-observer reliability and intra-observer reproducibility of these measurements was expressed as a kappa statistic. The radiological result was correlated with the clinical outcome measures using the Merle D'Aubigne scale, the Harris Hip Score, and the SF-36 score. RESULTS: Plain radiography was less effective in the detection of postoperative articular displacement (mean, 75.1% sensitive). The inter-observer and intra-observer agreement between reviewers was good to excellent in detecting reduction quality between the 2 modalities. Patient management was not altered by the findings of the CT scans. CONCLUSIONS: Although postoperative CT scanning of acetabular fractures in selective cases may be useful, issues such as higher cost, less effective allocation of resources, and excessive radiation doses do not support its routine use.     

Comparison of sagittal computed tomography and plain film radiography in a scaphoid fracture model

PURPOSE: To compare computed tomography (CT) in the sagittal plane and plain film radiography in the diagnosis of scaphoid fracture and displacement. METHODS: Three groups of scaphoids (no fracture, undisplaced fractures, fractures with displacement > 1 mm) from 11 cadaver wrists were prepared. Each wrist then was imaged by using sagittal plane CT scans in the long axis of the scaphoid and plain film imaging using 6 standard scaphoid views. Eight readers from 3 specialties read each group of images. The sensitivity and specificity for the presence of fracture and fracture displacement were calculated in addition to interobserver and intraobserver reliabilities for each. RESULTS: Both x-ray and CT scans showed a high sensitivity and specificity in detecting the presence of a fracture with no interspecialty differences. The sensitivity for displacement greater than 1 mm was lower for both modalities with no inter-specialty differences. The specificities for x-ray and CT for detecting displacement greater than 1 mm were 84% and 89%, respectively. The poor sensitivity for detecting displacement was explained by the low sensitivity of CT in the diagnosis of radial/ulnar displacement compared with x-ray and the low sensitivity of x-ray in the diagnosis of volar/dorsal displacement compared with CT scans. When fellowship-trained hand surgeons reviewed CT scans and plain films together the sensitivity and specificity for fracture displacement increased significantly. Intraobserver and interobserver reliability for both x-ray and CT scans was excellent except for the reading of CT scans among emergency physicians and for the reading of plain x-rays among senior house staff, representing moderate agreement. CONCLUSIONS: Based on these results both CT scans in the sagittal plane and plain films accurately detect fractures with a high degree of interobserver and intraobserver reliability, but they fall short in detecting displacement greater than 1 mm.     

Assessment of articular displacement of distal radius fractures

Intraarticular step and gap displacements represent the most common indication for surgical treatment of distal radius fractures. Most often, treatment decision making relies only on good-quality plain radiographs taken before and after reduction with measurement accuracy maximized by using the longitudinal axis method. When plain radiographs alone prove insufficient, CT scans or tomograms will significantly improve interobserver and intraobserver reliability of measurements, especially when evaluated using the arc method. Tomography is an effective method for postoperative evaluation of fractures immobilized in splints or casts. The role of MRI in assessing intraarticular distal radius fractures is limited to confirming injuries to carpal ligaments or the triangular fibrocartilage complex. Intraoperatively, we use fluoroscopy to obtain 30 degrees cephalad posteroanterior views and as 22 degrees lateral views to best observe articular surface reduction. Our current operative indications include fractures with radiocarpal or distal radioulnar joint step or gap deformities greater than 1-2 mm, gross distal radioulnar joint instability, or those with extensive metaphyseal comminution rendering them particularly unstable after closed reduction. In general, we tend to lean toward operative fixation in younger, more active patients.     

Computer-reconstructed radiographs are as good as plain radiographs for assessment of acetabular fractures

Radiographic evaluation of acutely injured patients with a displaced acetabular fracture usually includes plain radiographs and computed tomography (CT) scans. Because of patient and technologist factors, plain radiographs can be compromised and therefore can be insufficient for assessment of the fractured acetabulum. We conducted a study to determine whether computer-reconstructed radiographs (CRRs), plain radiograph-like images created from CT data, are equivalent to traditional radiographs for assessment of acetabular fractures. Five orthopedic surgeons with various trauma experience compared 77 radiographic images from 11 retrospectively identified patients with a displaced acetabular fracture. CRRs were found to be equal to plain radiographs for fracture pattern recognition, image clarity, level of information provided, and overall reviewer satisfaction. Reviewers were confident in their ability to assess fractures using CRRs and found them more aesthetically pleasing than plain radiographs. CRRs provide information equal to that of plain radiographs for assessment of displaced acetabular fractures and have the potential to overcome the problems associated with patient factors (discomfort, body habitus, fracture pattern, presence of overlying osseous structures, bowel gas and intestinal contrast materials) and technologist factors.     

Impacted intraarticular fragments of distal radius fractures: A radiographic characterization and analysis of reliability and diagnostic accuracy

BackgroundReduction using ligamentotaxis may not be effective enough to treat impacted intraarticular fragments of distal radius fractures. Articular incongruence resulting from the loss of reduction is a risk factor for postoperative osteoarthritis and worse clinical outcome. This study aimed to analyze the radiographic characterization of the impacted intraarticular fragments of distal radius fractures using two/three-dimensional computed tomography (CT). Further, we assessed the reliability and diagnostic accuracy in detecting the fragments using plain radiographs.MethodsWe analyzed 167 three-dimensional CT images of the intraarticular distal radius fractures and selected 12 fractures with impacted intraarticular fragments. We recorded the location, size, and displacement of the fragment using CT images. In addition, six examiners evaluated 25 fractures including those 12 fractures having the fragments using plain radiographs for detecting the fragments and their displacements. Further, we evaluated the reliability and diagnostic accuracy of the plain radiographs in the detection of the fragment.ResultsFifteen impacted intraarticular fragments were found in 12 wrists. The displacement of the scaphoid facet fragment was significantly larger than that of the lunate facet fragment in CT measurement (7.0 mm and 3.6 mm). Inter and intraobserver reliability of the diagnosis for the fragment in plain radiographs were poor and fair (κ: 0.14 and κ:0.27). Diagnostic accuracy in detecting the fragment in plain radiographs generated mean sensitivity: 0.4, mean specificity: 0.73, and mean accuracy: 0.58. The mean sensitivity in detecting a lunate facet fragment was lower than that of a scaphoid facet fragment in plain radiographs (0.24 and 0.44).ConclusionImpacted intraarticular fragments were found in 7% of intraarticular distal radius fractures. We observed low reliability and sensitivity in detecting the fragment using plain radiographs. Preoperative recognition of the fragments using plain radiograph were difficult, even though the magnitude of step-off of the scaphoid facet fragment was large.     

Intraobserver and interobserver reliabilty of measures of kyphosis in thoracolumbar fractures

Background contextConsensus documents have recently been developed enumerating the radiographic parameters thought to be most valid in the clinical evaluation of patients with thoracolumbar fractures.PurposeThe objective of this study was to assess the measurement reliability of plain X-rays, computed tomography (CT), and magnetic resonance imaging (MRI) and their inter-modality agreement, as the three imaging modalities are often clinically interchangeable. This process is an essential reliability evaluation of the measurement parameters being proposed.Study designThis study evaluated the interobserver and intraobserver reliability of plain radiographs, CT, and MRI measurements of sagittal kyphosis in thoracolumbar fractures.Patient sampleSuitable plain X-ray, CT, and MRI radiographic imaging of ten cases of thoracolumbar fracture were examined.MethodsSuitable plain X-ray, CT, and MRI radiographic imaging of ten cases of thoracolumbar fracture were examined by ten independent spine surgery fellowship-trained observers.Outcome measuresCobb angle measurement, Gardner segmental deformity angle, and anterior body compression percentage were measured.ResultsRegardless of the imaging modality or the parameter being measured, the intraobserver reliability is always better than the interobserver. Plain radiography has better overall, interobserver and intraobserver reliability, followed by CT and then MRI. Reliability is very high in general, with the highest reliability for intraobserver reliability of the linear measures on plain radiographs. The inter-modality agreement is highest for plain X-ray and CT.ConclusionsThis study demonstrates that Cobb angle measurement, Gardner segmental deformity angle, and anterior body compression percentage are reliable measures of thoracolumbar fracture kyphosis with very high interobserver and intraobserver reliability and very high inter-modality agreement of plain X-ray with CT.     

Radiologic evaluation of juvenile tillaux fractures of the distal tibia

This study evaluated the accuracy of plain radiographs and computerized tomography (CT) in assessing juvenile Tillaux fractures of the distal tibia. A simulated Tillaux fracture was made in four cadaver specimens and displaced 0, 1, 2, 3, and 5 mm. Plain radiographs and CT were performed on each specimen at each amount of displacement, and the results were compared with the actual amount of displacement present. Plain radiographs and CT were accurate within 1 mm in depicting the actual fracture displacement about 50% of the time. CT was more sensitive than plain radiographs in detecting fractures with >2 mm of displacement. Fracture displacement of >2 mm is generally considered an indication for fracture reduction. Because of its sensitivity in detecting fractures displaced >2 mm, CT is the preferred imaging modality in the assessment of juvenile Tillaux fractures.