张候(Z-H)骨折

1、张候骨折（张候骨折（Z-H骨折）骨折）胫骨下胫骨下1/3螺旋骨折合并后踝骨折螺旋骨折合并后踝骨折段彪段彪2016.8.15定义定义胫骨下胫骨下1/3螺旋骨折，后踝骨折与胫骨骨折线不连续，为一独立骨块螺旋骨折，后踝骨折与胫骨骨折线不连续，为一独立骨块病因病因胫骨骨折胫骨骨折多由于间接暴力所致运动中足踝部固定，患肢由于惯性继续向前运动并向外侧旋转，旋转外力持续作用于胫骨骨干，造成胫骨远端1/3薄弱部位（胫骨骨干由三边形移形为四边形）发生螺旋骨折，骨折线由内下到外上病因病因后踝骨折后踝骨折下胫腓后韧带受到较强内旋力的牵拉致后踝骨折足部固定后身体由于惯性继续向前运动,与距骨发生剪切造成后踝骨折踝关节受

2、到扭转应力和垂直应力的作用,距骨向后上撞击后踝造成骨折后踝的骨小梁纵向排列，骨折线常与胫骨纵轴平行Z-HZ-H骨折分型骨折分型显性骨折后踝骨折移位较大，通过X线检查即能确诊的Z-H骨折Z-H骨折骨折隐形骨折X线不能检出，经过CT或MR检查确诊即使普通X片未发现后踝骨折，但体格检查时如后踝存在压痛应加做CT或MR以除外隐形Z-H骨折，术中踝关节X片也非常必要Z-H骨折分度I度：X线和CT未检出后踝损伤，MR检出后踝损伤II度：X线未检出后踝损伤，CT和MR检出后踝损伤III度：X线检出后踝损伤，X片上表现为无移位或移位2mmIV度：X线检出后踝损伤，后踝骨折块明显移位或分离2mm漏诊原因分析漏诊

3、原因分析对1685例成人胫腓骨骨干骨折患者进行回顾性分析，发现胫骨下1/3螺旋形骨折合并后踝骨折28例，放射科漏诊率67.9%，临床骨科医师漏诊率53.6%漏诊漏诊原因原因对胫骨下1 /3 螺旋形骨折合并后踝骨折的认识认识不够,忽略了胫骨骨折有合并后踝骨折的可能性,尤其存在隐性后踝骨折隐性后踝骨折一些医院X 线片的清晰程度清晰程度影响了对骨折的诊断,甚至摄X 线片时只包括了膝关节而未包括踝关踝关节节多数骨科医师只注意到明显移位的胫腓骨螺旋形骨折,忽略忽略胫骨远端的微小的显性后踝骨折胫骨后踝骨折X 线片正位很难看到骨折线,而侧位片由于有腓骨腓骨的重叠的重叠,尤其是合并腓骨远段骨折时,更加难以分辨

4、According to our retrospective study, in the 1,685 fractures of the tibia, 288 cases showed spiral fractures of the tibia, whichwere combined with PMFs in 28 cases, the PMF incidencewas 9.7%. However, in our prospective study, 30 (88.2%) of34 fractures of the tibia were combined with the PMFs. Plain

5、 radiographs are often insufficient for detecting posterior malleolus fractures in conjunction with ipsilateral distal third diaphyseal tibia fractures. Using a preoperative CT protocol for tibial shaft fractures can significantly improve the ability to diagnose associated intra-articular fractures

6、that may not be evident on plain radiographs. Knowledge of these associated intra-articular fractures may prompt fracture stabilization and can prevent displacement during intramedullary nailing of tibia shaft fractures.Concomitant ipsilateral ankle and distal one-third spiral tibial shaft fractures

7、 are more common thanpreviously reported. Utilizing a new imaging protocol, wefound that the incidence of this combined injury was 84 %.Recognition of the ankle fracture component in this tibialshaft cohort can be important as it may alter the surgicalplan and postoperative management分度与治疗方式的选择分度与治疗

8、方式的选择I度度II度度III度度IV度度后踝可后踝可不予特不予特殊处理殊处理手术时密切注手术时密切注意并保护后踝，意并保护后踝，髓内钉不要过髓内钉不要过长、螺钉不要长、螺钉不要打入骨折线打入骨折线 ，必要时后踝行必要时后踝行克氏针或拉力克氏针或拉力螺钉固定螺钉固定手术时应首手术时应首先固定后踝先固定后踝骨折，以防骨折，以防操作中后踝操作中后踝骨折块发生骨折块发生移位移位后踝骨折后踝骨折块应予复块应予复位固定位固定,恢恢复踝关节复踝关节的稳定性的稳定性和完整性和完整性胫骨远端骨折合并后踝骨折，术中应先固定后踝胫骨远端骨折合并后踝骨折，术中应先固定后踝美国学者 Harish Kempegowda

9、 进行了一项回顾性研究，分析胫骨远端骨折和后踝骨折的关系，并探讨其骨折固定的先后次序。研究发现，后踝骨折常常伴有胫骨远端螺旋型骨折。为了避免术中骨折块移位，作者建议为了避免术中骨折块移位，作者建议先固定后踝先固定后踝，再行再行髓内钉髓内钉固定胫骨固定胫骨those treated with a mode of fixation other than an intramedullary nail for a tibial shaft fracture were excluded from the study.Posterior malleolar fracture was considered

10、as displaced if there was an intra-articular step off 2mm or there was a fracture gap of 2mmThe reduction for a posterior malleolus fracture was considered poor if there was an intra-articular step off 1mm or there was a fracture gap of 1mmOutcomes measured intra-operative displacement quality ofreduction(posterior malleolar fragment)病例分享张水金，女，54岁，入院日期：2016.6跌倒致右小腿肿痛3小时诊断：开放性胫腓骨骨折（gustiloI型）后踝髓内钉