改良后外侧入路治疗外踝后踝骨折的初步报道

目的观察改良后外侧入路锁定钢板治疗外踝后踝骨折的疗效。方法回顾性分析温州医科大学附属第二医院创伤骨科自2015年1月至2018年1月收治的25例累及外踝后踝骨折的患者资料,男13例,女12例;年龄18~70岁,平均43.1岁;踝关节损伤根据Lauge-Hansen分型:旋后外旋型Ⅲ度9例,旋后外旋型Ⅳ度11例,旋前外旋型Ⅳ度5例;合并踝关节脱位6例。后踝骨折根据Haraguchi分型全部为Ⅰ型骨折。均采用改良后外侧入路锁定钢板内固定外踝后踝。观察记录手术时间、骨折愈合时间以及术后并发症发生情况,末次随访时采用美国足踝外科协会(AOFAS)的踝-后足评分评价踝关节功能。结果本组患者手术时间50~100 min,平均70 min。21例患者术后获12~18个月(平均14个月)随访。术后3~5个月均骨性愈合。3例患者出现创口浅表感染,无术后粘连、深部感染,无长屈肌腱挛缩畸形、内固定松动、断裂等不良情况发生。末次随访时采用AOFAS的踝-后足评分评定疗效:优13例,良6例,可2例。结论改良后外侧入路可以同一切口解决后踝及外踝骨折,避免剥离长屈肌起点,减少了长屈肌术后粘连,值得推广。     

Short-Term Outcomes and Influencing Factors After Ankle Fracture Surgery

The present study investigated the factors influencing the early clinical outcomes after ankle fracture surgery. We included 88 patients, who had undergone implant removal surgery at 1 year after ankle fracture surgery, with ankle computed tomographic (CT) scans obtained before ankle fracture surgery and at implant removal available. We collected demographic information, including age, sex, the presence of diabetes mellitus, level of trauma energy, and fracture classification from the medical records. We also recorded the fracture height using the radiographs and CT images. The medial joint space and articular incongruity were assessed on the follow-up radiographs and CT scans. Bone attenuation was measured by placing a circular region of interest around the ankle joint on the preoperative CT image. The postimplant removal outcomes were assessed using 2 functional questionnaires, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale and Foot and Ankle Outcome Score (FAOS). Significant factors related to the AOFAS ankle-hindfoot scale scores and FAOS were identified through univariate analysis using age, sex, radiographic measurements, and CT findings as explanatory variables, followed by multiple regression analysis. On multiple regression analysis, the total FAOS was independently related to the AO classification (p?=?.003) and Lauge-Hansen classification (p?=?.003). The total AOFAS ankle-hindfoot scale score was related to articular incongruity (p?=?.044). The early clinical outcomes after ankle fracture surgery were affected by involvement of the ankle joint fracture rather than the lateral malleolus fracture height. Female sex and the presence of postoperative articular incongruity correlated with inferior early clinical outcomes.     

The isolated posterior malleolar fracture and syndesmotic instability: A case report and review of the literature

IntroductionAnkle fractures are among the most common type of fractures in the lower extremity. A posterior malleolar fracture is frequently part of a more complex ankle fracture and only in rare cases it occurs as isolated injury. Posterior malleolar fractures often occur with associated injuries, such as a Maisonneuve fracture or with bi- or trimalleolar ligamentous injuries. Knowledge about these associated injuries is essential to prevent missed diagnoses. The aim of this article is to describe the isolated posterior malleolar fracture, the possible associated injuries, the diagnostic work-up and therapeutic consequences.Presentation of caseWe present a case of a 26-year-old male patient who sustained an isolated posterior malleolar fracture with 4.5 years follow-up.DiscussionIsolated fractures of the posterior malleolus are uncommon injuries. Diagnosis, treatment and outcome can seldom be extracted from large series. However, several cases have been described in literature, which we have summarized.ConclusionThis case report and literature review shows that isolated posterior malleolar fractures might occur as part of a more complex ankle injury, in combination with a fracture of the lower leg or after high energy trauma. Physicians should be aware of these associated injuries. Diagnostic work-up should include X-rays of the knee and lower leg and a CT scan of the ankle. If diagnosed and treated properly, isolated posterior malleolar fractures have a good long-term functional outcome.     

The association between medial malleolar fracture geometry,injury mechanism,and syndesmotic disruption

BackgroundPrecise correlations between medial malleolar fracture geometry and fracture mechanism have not been thoroughly described. This study sought to determine the prevalence of different medial malleolar fracture types and to elucidate the association between fracture geometry and fracture mechanism.MethodsThe records of 112 medial malleolar ankle fractures were reviewed. For each fracture, the direction of the fracture line in the medial malleolus (transverse, oblique, vertical, or comminuted), the Lauge-Hansen classification, and the presence or absence of syndesmotic injury was recorded. Bivariate correlation analysis was performed to determine if correlations existed.ResultsTransverse fractures were the most prevalent type of medial malleolar fracture [n = 64 (57%)], and they correlated with supination-external rotation injuries. These were followed by oblique fractures [29 (26)], which correlated with pronation-external rotation injuries [29 (26)], and vertical fractures [7 (6)], which correlated with supination-adduction injuries [9 (8)]. Comminuted fractures [12 (11)] and pronation-abduction injuries [22 (20)] did not correlate with any other categories. Syndesmotic injuries were correlated with transverse fractures, bimalleolar fractures, and pronation-external rotation injuries.ConclusionMedial malleolar fractures can be divided into four fracture types: transverse fractures, which correlated with supination-external rotation injuries; oblique fractures, which correlated with pronation-external rotation injuries; vertical fractures, which correlated with supination-adduction injuries; and comminuted fractures, which did not correlate with a particular type of injury. Syndesmotic injury was positively correlated with transverse fractures of the medial malleolus, bimalleolar fractures, and pronation-external rotation injuries. These findings suggest that medial malleolar fracture geometry can provide valuable information for the clinician when classifying and managing ankle fractures.     

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.     

Anterior tibiofibular ligament avulsion fracture in weber type B lateral malleolar fracture

BACKGROUND: The purpose of this study was to determine the incidence, relationship with the ankle diastasis, and effect of treatment of the anterior tibiofibular ligament avulsion fracture (Wagstaffe fracture) combined with the Weber type B lateral malleolar fracture. METHODS: This study reviewed 94 cases of ankle fractures treated with operative methods. RESULTS: There were 52 cases of Weber type B lateral malleolar fractures and 13 cases of Wagstaffe fractures combined with them (25%). Ankle diastases were diagnosed in 20 cases (38.5%) in all Weber type B fractures and 11 (84.6%) of the 13 Wagstaffe fractures. CONCLUSION: The Wagstaffe fracture can be a good diagnostic clue of ankle diastasis in Weber type B lateral malleolar fracture. The accurate reduction and fixation of the avulsed fragment is important for restoration of the stable distal tibiofibular joint and to prevent the chronic ankle joint pain caused by impingement of the avulsed fragment.     

Deltoid ligament integrity in lateral malleolar fractures: a comparative analysis of arthroscopic and radiographic assessments

Foot and ankle surgeons often rely on the medial clear space to evaluate competency of the deep deltoid ligament when evaluating ankle fractures. This investigation assesses the integrity of the deep deltoid ligament after lateral malleolar fracture by using direct arthroscopic visualization and medial clear-space separation on plain film radiographs. The objectives of this study were to test the reliability of medial clear-space separation and the Lauge-Hansen classification scheme in predicting deep deltoid rupture in displaced lateral malleolar fractures. The medial clear space was measured on injury radiographs of 40 patients with an isolated displaced lateral malleolar fracture who underwent open reduction and internal fixation. Injury radiographs were classified according to the Lauge-Hansen scheme. Direct arthroscopic visualization was used to evaluate the deep deltoid ligament under manual stress before fracture reduction. The mean preoperative medial clear space in patients with a deep deltoid rupture (n = 13) was 6.6 +/- 2.4 mm (range, 4 to 12 mm), and in patients without a deep deltoid rupture (n = 26), it was 4.0 +/- 1.0 mm (range, 2.5 to 6 mm) (P =.002, 2-sample t test). At an injury medial clear space > or =3 mm, the false positive rate for deltoid rupture was 88.5% (P =.54, Fisher's exact test). At > or =4 mm, the false positive rate was 53.6% (P =.007). All fractures were rotational injuries according to the Lauge-Hansen system. Three fractures were not classifiable; another 3 fractures showed deltoid ligament integrity opposite the expected finding. The results indicate that, in isolated displaced fractures of the lateral malleolus, radiographic widening of the medial clear space is not a reliable indicator for deep deltoid rupture. Some fractures considered stable by the Lauge-Hansen classification may require careful scrutiny to rule out deep deltoid injury.     

Ankle Fracture with a Complex Injury Mechanism and Misleading Hook Test Result: A Case Report

Ankle fractures and their mechanisms of injury can be complex. We report a case of a patient with an uncertain mechanism of injury and an uncommon combination of lower extremity fractures, which fit the criteria for a Lauge-Hansen classification pronation-external-rotation fracture, Maisonneuve fracture, Wagstaffe fracture, and posterior pilon fracture. Plain radiographs and computed tomography scan revealed Chaput tubercle avulsion fractures, an anterior distal fibular fracture fragment, multiple lateral malleolar fractures, a posterior malleolar fracture fragment with proximal displacement, a die-punch fragment between the posterior malleolar fragment and the tibia, a proximal fibular fracture, and possible ankle syndesmotic diastasis. Intraoperative hook test was negative after fixation of the fractures, so syndesmotic fixation was not performed. At 3-month follow-up, plain radiographs showed obvious syndesmotic diastasis. At 1-year follow-up, symptoms persisted and syndesmotic fusion was recommended but declined by the patient. This case demonstrates that both ankle fractures and their mechanisms of injury can be remarkably complex and confusing, posterior pilon fractures can occur along with pronation-external-rotation ankle fractures, syndesmotic fixation should be considered for all patients with Maisonneuve fractures, reliance on the hook test for surgical management decisions may not always be reliable, and there exists a need for a more accurate and reliable intraoperative test to determine the presence of ankle syndesmotic injury.     

The influence of foot and ankle injury patterns and treatment delays on outcomes in a tertiary hospital; a one-year prospective observation

BackgroundAnkle and foot fractures are amongst the most common injuries, and patterns may vary from primary care set up to tertiary hospitals. Severe foot injuries are projected to have significantly worse outcomes and surgical delays are thought to alter prognosis.MethodsAll patients with foot and ankle trauma were prospectively evaluated at a Tertiary trauma centre over one year. The incidence, fracture patterns, risk factors, and outcomes were evaluated, and cases were divided into simple foot injuries (FASS ≤ 3) and severe foot injuries (FASS > 3). Injury mechanisms, associated injuries, and delays in treatment were evaluated, and outcomes were analyzed using Visual–Analogue Scale Foot and Ankle (VASFA), Maryland Foot Score (MFS) and Foot and ankle disability index (FADI).Results294 Foot and Ankle injuries (51 females, 243 males) were encountered in 2919 trauma cases (incidence of 10%). 80 patients (27.2%) had simple foot injuries and 214 (72.8%) had severe foot injuries. 29 patients (9.9%) were below 18years; most (65.3%) patients were between 18 and 45 years age. Road traffic accident was most commonest mode of injury, with ankle fractures (30.6%) the most common. Metatarsal fractures (27.9%) and calcaneal fractures (21.4%) were 2nd and 3rd most common injuries in the foot. Surgical delay averaged 1 day in both severe and simple injuries. Injury led to 32 (10.9%) below knee amputations. Outcome evaluation in 127 (91 severe, 36 simple injuries) patients showed mean Maryland foot score of 89.30 in simple injury group and 84.87 in severe injury group. Mean VASFA score was 82.87 (simple) and 81.87 in severe injury, and mean FADI score was 93.13 (simple) and 91.05 (severe injury). More detailed analysis revealed that more good scores (64.4%) were documented in severe injuries group, and more excellent scores (52.8%) in simple injuries group.ConclusionFoot injuries constitute 10% of all orthopaedic trauma at tertiary hospitals; Majority of them are severe foot injuries, with 68.7% being open injuries. Surgical delay was similar in simple and severe foot and ankle injuries. Outcomes of severe injuries were similar to simple foot and ankle injuries, reflecting on the quality of care that could be administered to them when they present to tertiary hospitals.     

复杂外旋型踝关节骨折中后踝的治疗策略

目的:总结和探讨复杂外旋型踝关节骨折中后踝固定的适应证、手术方法及疗效,阐明后踝骨折解剖复位、坚强内固定的重要性。方法:2007年7月至2009年6月内固定治疗后踝骨折32例,男21例,女11例;年龄19～68岁,平均36岁。按照Lauge-Hansen分型,旋前外旋型Ⅳ型13例,旋后外旋型Ⅲ型7例,旋后外旋型Ⅳ型12例。术后早期功能锻炼,同时定期随访,对踝关节功能恢复进行评定。结果:32例患者均获随访,时间7～20个月,平均14.5个月,所有骨折获得骨性愈合。疗效评定按照美国足踝骨科协会(AOFAS)推荐的足踝评分系统评分如下:优(90～100分)23例,良(80～89分)7例,可(70～79分)2例,差(<69分)0例。结论:后踝骨折良好的复位、坚强的固定及早期功能锻炼对踝关节功能恢复、降低创伤性关节炎的发生具有重要意义。     

Functional results and complication analysis after total ankle replacement: Early to medium-term results from a Portuguese and Spanish prospective multicentric study

BackgroundAnkle arthroplasty is increasingly being used to treat end-stage ankle osteoarthritis.MethodsBetween January 2005 and January 2011, 159 patients have been included in an ongoing prospective multicentric study analysing the results of total ankle arthroplasty in Portugal and Spain. 119 patients (119 replacements) were available for review and were evaluated for range of motion (ROM), clinical status (American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score), complications and survivorship rate.ResultsMean follow-up was 39 months. A total of 17 complications were reported, with 7 leading to subsequent surgery (94.1% survivorship rate). Of these, there were two infections (98.3% survivorship rate), two painful subtalar arthritis, one instability, one malalignment and one tibial bone cyst. Complications not requiring further surgery were 6 intra-operative malleolar fractures and 4 cases of skin necrosis.ConclusionsAdequate patient selection and a thorough knowledge of the surgical technique are mandatory to reduce the number of complications and increase ankle arthroplasty survivorship.     

Is It an Overlooked Injury? Magnetic Resonance Imaging Examination of Occult Talus Lesions Concomitant to Tibial Shaft Fracture

Long-term studies have shown that 10% to 20% of patients continue to experience ankle pain years after tibial fracture, which causes poor functional results and dissatisfaction. The aim of this study was to show that there could be a talus injury in patients with a tibial shaft fracture and to reveal occult talus lesions with magnetic resonance imaging (MRI) examination. Fifty-two patients with a tibial shaft fracture, with closed epiphyses, not extending to the joint and with no problems in the application of MRI examination were included. All patients underwent intramedullary tibial nailing. Patients with a lesion detected on MRI were planned to be examined by MRI again at mean of 12 months later. Ankle function of the patients were evaluated with the American Orthopaedic Foot and Ankle Society, Freiburg, and Weber scoring systems at 3, 6, and 12 months postoperatively. At the first MRI, 22 (42.3%) patients with tibial shaft fracture were found to have talus lesions: 7 (13.5%) had osteochondritis dissecans, 12 (23.1%) had edema, and 3 (5.8%) had cysts. A second MRI was planned for patients with edema and osteochondritis dissecans at a mean of 12 months. Finally, at 12 months, MRI examinations revealed osteochondritis dissecans and edema in 9 (17.3%) and 8 (15.4%) patients, respectively. In the evaluations of the patients according to the ankle scoring systems, the scores of the patients with pathology determined in the talus were significantly worse statistically than those of patients with no pathology determined at 3, 6, and 12 months postoperatively. Atalus lesion accompanied the tibial shaft fracture at a rate of 37%. The talus injuries were seen especially with an indirect mechanism of trauma, in distal third fractures, in spiral fractures, and when the tibial fracture was accompanied by a lateral malleolar fracture. In the presence of findings indicating talus injury in cases of tibial shaft fracture, the talus should be evaluated with ankle MRI.     

The ability of the Lauge-Hansen classification to predict ligament injury and mechanism in ankle fractures: an MRI study

OBJECTIVES: The Lauge-Hansen classification system was designed to predict the mechanism and ligament injury patterns of ankle fractures on the basis of x-rays. The purpose of this study was to evaluate the accuracy of these predicted injury sequences using magnetic resonance imaging (MRI) in a series of patients with ankle fractures. DESIGN: Retrospective cohort. SETTING: Two university level 1 trauma centers. PATIENTS: Fifty-nine patients with operative ankle fractures who were evaluated with both x-ray and MRI were included. INTERVENTION: All patients had a standard 3-view ankle x-ray series before fracture reduction, followed by an MRI. All plain x-rays were assigned to a Lauge-Hansen category by an experienced orthopedic traumatologist. MRI studies were subsequently read by an MRI musculoskeletal radiologist for the integrity of the ankle ligaments. MAIN OUTCOME MEASUREMENTS: After evaluation of the x-rays, fractures were classified according to the system of Lauge-Hansen, and the predicted presence, sequence, and mechanism of injury was determined. These were then compared to the actual injured structures on MRI in each case, and the ability of the Lauge-Hansen system to accurately predict the complete injury pattern was determined for the entire cohort. RESULTS: Average patient age was 59 (range: 18 to 84) years. Of the 59 ankle fractures evaluated, 37 (63%) were classified as supination external rotation, 11 (19%) were pronation external rotation, 1 (2%) was supination adduction, and 10 (17%) were not classifiable on the basis of the Lauge-Hansen system. Of the 49 fractures that fit into Lauge-Hansen categories, 26 (53%) had patterns of ligamentous injury and fracture morphology that did not coincide with the Lauge-Hansen predictions. A common fracture pattern was observed in 8 of the 10 unclassifiable fractures, which included a high spiral fracture of the fibula, vertical shear fracture of the medial malleolus, posterior malleolar fracture, and complete tears of the anterior-inferior tibiofibular ligament and the interosseous membrane. In addition, over 65% of patients in this series had complete ligamentous injury and a fracture of the malleolus to which the ligament attaches. CONCLUSIONS: These results demonstrate that the Lauge-Hansen classification system may have some limitations as a predictor of the mechanism of injury and the presence of soft-tissue damage associated with ankle fractures. The identification of a novel pattern of ankle fracture also illustrates how the system fails to describe all possible fracture patterns. For these reasons, we recommend that the Lauge-Hansen system be used only as a guide in the diagnosis and management of ankle fractures and not solely relied upon for treatment decisions. Although the exact clinical implications of the variety of ligamentous injuries observed on MRI are yet to be determined, this technique may be useful in individual cases in which doubt about joint stability and soft-tissue integrity exists. Additionally, MRI may be helpful in planning surgical approaches in atypical fractures in which injury patterns are less predictable solely on the basis of x-ray.     

Extraperiosteal plating of pronation-abduction ankle fractures

BACKGROUND: Pronation-abduction ankle fractures frequently are associated with substantial lateral comminution and have been reported to be associated with the highest rates of nonunion among indirect ankle fractures. The purpose of the present study was to report the technique for and outcomes of extraperiosteal plating in a series of patients with pronation-abduction ankle fractures. METHODS: Thirty-one consecutive patients with an unstable comminuted pronation-abduction ankle fracture were managed with extraperiosteal plating of the fibular fracture. The average age of the patients was forty-four years. There were nineteen bimalleolar and twelve lateral malleolar fractures with an associated deltoid ligament injury. No attempt to reduce the comminuted fragments was made as this area was spanned by the plate. The patients were evaluated functionally (with use of the American Orthopaedic Foot and Ankle Society score), radiographically, and clinically (with range-of-motion testing). RESULTS: Immediate postoperative and final follow-up radiographs showed that all patients had a well-aligned ankle mortise on the fractured side as compared with the normal side on the basis of standardized measurements. All fractures healed without displacement. At a minimum of two years after the injury, the average American Orthopaedic Foot and Ankle Society score (available for twenty-one patients) was 82. The range of motion averaged 13 degrees of dorsiflexion and 31 degrees of plantar flexion, with one patient not achieving dorsiflexion to neutral. There were no deep infections, and one patient had an area of superficial skin breakdown that healed without operative intervention. CONCLUSIONS: Extraperiosteal plating of pronation-abduction ankle fractures is an effective method of stabilization that leads to predictable union of the fibular fracture. The results of this procedure are at least as good as those of other techniques of open reduction and internal fixation of the ankle, although specific results for pronation-abduction injuries have not been previously reported, to our knowledge.     

The Current UK Consensus on the Management of Weber B and Posterior Ankle Fractures: A Questionnaire Study as Part of the Acute Management of Ankle Fractures (AUGMENT) Audit

Ankle fractures are common conditions which are associated with significant morbidity when managed incorrectly. With the incidence due to triple by 2030, standards of practice were created by the British Orthopaedic Association and the British Orthopaedic Foot and Ankle Society to ensure optimal treatment. In spite of this, anecdotally there is still a variation in practice and therefore a questionnaire study was designed to explore clinician decision-making around Weber B and Posterior Malleolus ankle fractures. Five scenarios explored management regarding minimally and grossly displaced injuries, as well as the use of further imaging. The questionnaires were distributed via AUGMENT collaborators at their sites and at the British Orthopaedic Foot and Ankle Society congress 2018. About 315 questionnaires were completed and included in analysis. For Weber B injuries, overall there was a consensus across all respondents with minimally displaced and grossly displaced fractures being treated conservatively and operatively respectively. For Posterior Malleolus injuries, there was variation in practice between Foot and Ankle specialists and their non-Foot and Ankle colleagues. Computed tomography (CT) was more likely to be used to assess these injuries by specialists (97.50 vs 69.79%) and these injuries were more likely to be treated operatively across the board. This study identified key variation in practice of the management of Posterior Malleolar ankle fractures, including the use of imaging to further define the anatomy and the decision to operate. Foot and Ankle surgeons were more likely to organize CT scans and to surgically manage these injures.     

踝关节骨折合并Tillaux-Chaput和Volkmann骨折的临床特点及治疗方法

 目的 探讨踝关节骨折合并Tillaux-Chaput和Volkmann骨折的临床特点及治疗方法。方法 2005年9月至2012年1月采用手术治疗并获得随访的踝关节骨折合并Tillaux-Chaput和Volkmann骨折患者15例,男8例,女7例;年龄16~57岁,平均27.3岁;均为内踝、腓骨骨折合并Tillaux-Chaput和Volkmann骨折。8例Tillaux-Chaput骨折经X线片确诊,7例经CT扫描确诊。依据踝关节骨折Lauge-Hansen分型,旋前外展型Ⅲ度11例,旋前外旋型Ⅳ度4例。采用后外侧入路,复位腓骨骨折后以钢板固定,复位Volkmann骨折后以1~2枚空心螺钉固定;采用内侧弧形切口显露内踝骨折,复位后以空心螺钉固定;于胫骨前结节做纵行切口,复位Tillaux-Chaput骨折后以空心螺钉固定。根据美国足踝外科协会(American Orthopaedic Foot and Ankle Society,AOFAS)踝与后足评分标准评价踝关节功能。结果 随访8~20个月,平均12.5个月。骨折均愈合,愈合时间12~36周,平均23.5周。末次随访时12例行走正常,3例轻度跛行。AOFAS评分71~94分,平均85.4分;其中优9例、良4例、可2例,优良率86.7％(13/15)。3例踝关节活动受限,3例下地负重行走时疼痛不适。结论 Tillaux-Chaput及Volkman骨折多发生于旋前外展型踝关节骨折时,X线检查容易漏诊,CT检查可明确诊断,手术治疗要求精确复位及固定。
     

Does the Lauge-Hansen Injury Mechanism Predict Posterior Malleolar Fracture Morphology?

The Lauge-Hansen ankle fracture classification system is widely accepted and is utilized to describe and predict ankle fracture patterns based on the mechanism of injury. Multiple studies have shown inconsistencies in the Lauge-Hansen's ability to predict fracture patterns based on the mechanism of injury. We set out to determine if the posterior malleolar fracture pattern is associated with the fracture types described by Lauge-Hansen. In this retrospective cohort study, we reviewed 153 patients with trimalleolar ankle fractures as diagnosed using computed tomography scans. Timing of injury was from February 2013 to August 2017. Patient ages ranged between 18 and 89 years old. Each patient had a complete clinical and radiographic workup including a preoperative computed tomographic scan following initial fracture reduction in the emergency room. We classified each ankle fracture based on plain film radiographs using the Lauge-Hansen classification scheme. Each individual posterior malleolar fracture was evaluated on computed tomography imaging and described using both the Haraguchi and Bartonicek-Rammelt classification systems. Of the 153 patients identified with trimalleolar ankle fractures, 70% were female (±20%), the mean age was 51 y (±8 y), and the mean body mass index was 30 kg/m² (±3 kg/m²). We did not observe a significant association between the Lauge-Hansen injury mechanism and either the Bartonicek-Rammelt or the Haraguchi trimalleolar ankle fracture classification systems (chi-square correlation tests p > .05).     

伴撕脱性骨折的踝关节"Logsplitter"损伤未行下胫腓联合螺钉固定的疗效

目的探讨"Logsplitter"损伤伴Tillaux-Chaput骨折/Wagstaffe-Lefort骨折与Volkmann骨折未行下胫腓螺钉固定的疗效。方法回顾性分析新疆医科大学第六附属医院骨科自2015年1月至2018年12月采用切开复位内固定治疗的16例踝关节"Logsplitter"损伤伴Tillaux-Chaput骨折/Wagstaffe-Lefort骨折的患者资料。男11例,女5例;年龄27~56岁,平均36.4岁;开放性损伤2例(根据Anderson-Gustilo分型:Ⅱ型1例,ⅢA型1例),闭合性损伤14例;骨折AO/OTA分型均为44-C型。根据Lauge-Hansen分型:旋前外展型9例,旋前外旋型3例,旋后外旋型4例。采用外侧单一切口,复位腓骨骨折后用接骨板固定,Tillaux-Chaput骨折/Wagstaffe-Lefort骨折采用螺钉或克氏针固定,Volkmann骨折用螺钉固定。术后采用美国足踝外科协会(AOFAS)的踝-后足评分、肌肉骨骼功能(SMFA)障碍指数、肌肉骨骼功能困扰指数评价踝关节功能。结果所有患者术后随访8~27个月,平均21.3个月。X线片示所有骨折均达骨性愈合,愈合时间12~18周,平均14.8周。末次随访时13例均行走正常,3例轻度不适。AOFAS的踝-后足评分为86~100分(平均96.3分),其中优12例,良3例,差1例。SMFA障碍指数为8~17分(平均15.9分),SMFA困扰指数为3~9分(平均6.5分)。结论"Logsplitter"损伤伴Tillaux-Chaput骨折/Wagstaffe-Lefort骨折与Volkmann骨折时,术中固定Tillaux-Chaput骨折块或Wagstaffe-Lefort骨折及Volkmann骨折重建下胫腓水平稳定"环",未行下胫腓螺钉固定,可以获得满意的疗效。     

Ankle fracture: radiographic approach according to the Lauge-Hansen classification

Ankle fractures account for 9 % of fractures (Clare in Foot Ankle Clin 13(4):593–610, 1) representing a significant portion of the trauma workload; proximal femoral fractures are the only lower limb fracture to present more frequently. Ankle fractures have a bimodal age distribution with peaks in younger males and older females (Arimoto and Forrester in AJR Am J Roentgenol 135(5):1057–1063, 2). There has been threefold increase in the incidence among elderly females over the past three decades (Haraguchi and Armiger in J Bone Joint Surg Am 91(4):821–829, 3). In 1950, Lauge-Hansen devised a classification of ankle fractures based on the position of the foot and the deforming force at the time of injury. This has been widely accepted by orthopedists, but is not in general use by radiologists. Identification of the fractures and classification of the type of injury allows diagnosis of the otherwise occult ligamentous injuries. Three radiographic views of the ankle (anteroposterior, mortise, and lateral) are necessary to classify an injury with the Lauge-Hansen system. Two additional criteria are also necessary: the position of the foot at the time of injury and the direction of the deforming force.     

Posterior Malleolus Fracture Displacement Is Associated with Rotational Ankle Fracture Stability in Patients Without Medial Malleolar Fractures

Background

The optimal method for the determination of ankle stability remains controversial in rotational ankle fractures without medial bony injury.

Questions/Purposes

The purposes of this study were to (1) evaluate whether posterior malleolar (PM) fracture displacement is associated with deltoid ligament injury in supination-external rotation (SER) ankle fractures and (2) compare the diagnostic accuracy of PM displacement and magnetic resonance imaging (MRI) evaluation of the deep deltoid ligament in identifying fractures with deltoid ligament incompetence.

Methods

Patients with rotational bimalleolar injuries containing lateral malleolar and PM fractures without bony medial injury were included. After operative lateral and PM fixation, an external rotation stress test was performed to evaluate deltoid ligament stability. Operative dictations were reviewed to confirm injury pattern, stability on stress test, and visual inspection of the deltoid ligament. Maximum PM displacement was assessed on lateral X-ray. Pre-operative MRI of the ankle was performed following closed reduction and splinting.

Results

The final cohort consisted of 13 trimalleolar equivalent fractures (torn deltoid ligament) and 20 bimalleolar fractures (medial malleolus and deltoid ligament intact). Average PM displacement was significantly higher for SER trimalleolar equivalent patterns when measured on lateral X-ray. The sensitivity of detecting trimalleolar equivalent fracture was higher on all reported X-ray findings than the sensitivity obtained by the reported MRI findings of deltoid ligament injury.

Conclusion

PM displacement on X-ray is a useful adjuvant along with external rotation stress radiography and MRI evaluation of deep deltoid integrity to distinguish between stable and unstable fracture patterns and thus helps facilitate treatment decisions.