手术-jones骨折(第5跖骨基底骨折)切开复位内固定术

1、Jonesmann骨折指第五跖干骺端与骨干连接部骨折。英国骨科医生Sir Robert Jones（18571933）自己跳舞后发生此类骨折并首先描述，故此得名。Jones fractures occur in a small area of the fifth metatarsal that receives less blood and is therefore more prone to difficulties in healing. A Jones fracture can be either a stress fracture (a tiny

2、 hairline break that occurs over time) or an acute (sudden) break. Jones fractures are caused by overuse, repetitive stress, or trauma. They are less common and more difficult to treat than avulsion fractures.      A Jones fracture is a fracture of the

3、60;diaphysis of the fifth metatarsal of the foot. The fifth metatarsal is at the base of the small toe. The proximal end, where the Jones fracture occurs, is in the midportion of the foot. Patients who sustain a Jones fracture have pain over this area,swelling

4、, and difficulty walking. The fracture was first described by British orthopedic surgeonSir Robert Jones, who sustained this injury himself while dancing, in the Annals of Surgery in 1902.        Fractures of the fifth metatarsal of the foo

5、t are surprisingly controversial among radiologists, particularly concerning proximal metatarsal fractures. Some term these fractures Jones fractures, others dancers fractures, while others simply term them proximal metatarsal fractures. According to Orthopedic Radiology (Adam Greensp

6、an, 3rd edition), a "true Jones" fracture occurs one inch distal to the base of the fifth metatarsal. It is not due to peroneus brevis tendon avulsion but rather a twisting inversion injury to the foot. Greenspan states that more proximal injuries are frequently misinterpreted as Jone

7、s fractures but really are avulsion fractures by the peroneus brevis tendon. These latter fractures heal quickly, while more distal fractures may undergo fibrous union only.A patient stepped off a curb and sustained a fracture of the proximal aspect of the fifth metatarsal. According to Greenspan, t

8、his would be termed a "true Jones fracture."In contradistinction, this patient sustained a fracture of the proximal aspect of the fifth metatarsal. Greenspan terms this an avulsion injury.In an avulsion fracture, a small piece of bone is pulled off the main portion of the bone by a tendon

9、or ligament. This type of fracture is the result of an injury in which the ankle rolls. Avulsion fractures are often overlooked when they occur with an ankle sprain.  Treatment： If a Jones fracture is not significantly displaced, it can be treated with a cast, splint or walking b

10、oot for four to eight weeks. Patients should not place weight on the foot until instructed by their doctor. Three-fourths of fractures treated like this should heal.In the case of acute fracture in an athlete, a dynamic compression plate can be placed on the tension side of the fracture, K-Wire with

11、 Monofiament wire in a figure 8 fashion due to the nature of a transverse fracture. Internal fixation with cortical or cancellous screw would require an oblique fracture that could be addressed through "The rule of 2's" in regards to Internal fixation with screws.Other treatments commo

12、nly encouraged are increased intake of vitamin D and calcium.This injury must be differentiated from the physiologic developmental apophysis commonly and normally occurring at this site in adolescents. Differentiation is possible by characteristics such as absence of scleros

13、is of the fractured edges (in acute cases) and orientation of the lucent line: transverse (at 90 degrees) to the metatarsal axis for the fracture (due to avulsion pull by the peroneus brevis muscle inserting at the proximal tip) - and parallel to the metatarsal axis in the case of the apophysis.Jone

14、s fractures can become chronic conditions if the fracture fails to unite, or heal. If this is the case, surgery will likely be recommended to secure the fracture in place with a screw, and bone graft may be used to stimuate a healing response.- Surgical Treatment: (Jones Frx);     - p

15、atient is position in partial lateral position on bean bag;     - flouroscopy:           - under flourscopic guidence, a K wire is inserted for determination of proper position and length;           - most common mi

16、stake is to direct the drill plantarly, rather than parallel w/ the shaft of metatarsal;           - second mistake is too position the guide wire using the oblique view;                  - note that the metatarsal

17、shaft is more narrow on the AP view, and it is possible for the pin to be centered on the oblique view                           where as on AP view the pin is eccen

18、trically positioned;     - incision:           - longitudinal incision is made over distal metatarsal;           - take care to avoid branches of the sural nerve which can course dorsally, and la

19、terally over metatarsal;           - peroneus brevis is retracted inferiorly;           - insertion of this tendon may obscure the proper drill entry site;     - local bone graft:       

20、0;   - can be obtained from tuberosity and from bone bits from the drill;     - implants:           - consider insertion of 4.5 cancellous bone screws, 4.5 mm cannulated screws (which are used in most cases) bu

21、t have available 5.5 cannulated (and  solid) screws and 6.5 mm cannulated screws;                  - diameter should depend on width of the canal (let the screw tap help determine the best size);

22、           - in either case, threads must cross the frx line;           - length is usually between 40-55 mm;           - consider countersinking the screw to avoid prominence of the screw h

23、ead;           - in report by IP Kelly, authors noted that failure is more likely when smaller diameter screws are used;                  - experimental Jones fractu

24、res were created in 23 pairs of human cadaver fifth metatarsals, which were fixed using either 5.0 mm or 6.5 mm screws;                  - frx stiffness and pull-out strengths were measured for either screw type and relationships with bone 

25、density and canal diameter were determined;                  - poor thread purchase within the medullary canal was noted with the 5.0 mm screws, while excellent purchase was noted with 6.5 mm screws;       

26、0;          - pull-out strength testing revealed significantly higher pullout strengths for the larger 6.5 mm screws;                  - the authors conclude that larger diameter screws may be more ap

27、propriate for intramedullary screw fixation of Jones fractures;           - ref: Treatment of Jones Fracture Nonunions and Refractures in the Elite Athlete Outcomes of IM Screw Fixation With Bone Grafting    - post op: pati