踝关节骨折课件

踝关节骨折EPIDEMIOLOGYOFANKLEFRACTURES1.芬兰大于60岁的人群，踝关节骨折的发生人数从每10万57人（1970年），增加到130人（1994年）。2.危险因素：体重指数的增加；吸烟的影响3.绝经和一般身体状况的好坏与踝关节骨折的发生无关.RadiographicMeasurementsofAlignmentandStability

Radiographicappearanceofthenormalankleonmortiseview.Thecondensedsubchondralboneshouldformacontinuouslinearoundthetalus.Talocruralangleshouldbeapproximately83degrees.Whentheoppositesidecanbeusedasacontrol,thetalocruralangleoftheinjuredsideshouldbewithinafewdegreesofthenoninjuredside.Themedialclearspaceshouldbeequaltothesuperiorclearspacebetweenthetalusandthedistaltibiaandlessthanorequalto4mmonstandardradiographs.Thedistancebetweenthemedialwallofthefibulaandtheincisuralsurfaceofthetibia,thetibiofibularclearspace,shouldbelessthan6mm.Thecondensedsubchondralboneshouldformacontinuouslinearoundthetalus.

Talocruralangleshouldbeapproximately83degrees.MedialClearSpaceEvaluationofSyndesmosis

Evaluatingsyndesmoticwideningisperhapsthemostdifficulttaskwheninterpretingankleradiographsforalignmentandstability.Thesimplestapproachistomeasurethedistancebetweenthemedialwallofthefibulaandtheincisuralsurfaceofthetibia.Thistibiofibularclearspaceshouldbelessthan6mmonbothAPandmortiseviewsWefindthisapproachsimplerthanmeasuringoverlapoftheanteriortubercleofthetibiaonthefibula,becausethelattermeasureisrotationallydependent.ClassificationsinCurrentUseLauge-HansenClassificationAO/OrthopaedicTraumaAssociationFractureClassificationLauge-HansenClassification1.依据踝关节骨折损伤时,足的位置和外力作用的方向.2.足的位置:旋前和旋后3.外力致使距骨外旋,内翻,外翻.4.分为旋后-外旋(SER),旋后-内收,旋前-外旋(PER),旋前-外展.Anteroposteriorandlateralradiographsshowanunstablesupination-external

rotationstageIVanklefracturewiththecharacteristicobliquedistalfibulafractureandamedialsideinjury.Ananteroposteriorradiographofasupination-adduction

anklefracturewithatransversefibulafractureandanimpactedmedialmalleolarfracture.Ananteroposteriorradiographofatypicalpronation-abductionanklefracture.Thefibulaislaterallycomminuted.特殊骨折

Dupuytren骨折－－一种少见的旋前－外展型损伤，即腓骨高位骨折，胫骨下端腓骨切迹撕脱骨折，三角韧带断裂同时有下胫腓分离。Tillaux骨折－－旋前－外旋型2度，胫骨远端前结节撕脱骨折。Maisonneuve骨折－－旋前－外旋型骨折中，如果腓骨骨折达到中上1/3或腓骨颈骨折或上胫腓分离。AO/OrthopaedicTraumaAssociationFractureClassificationItisanextensionoftheclassificationintroducedbyDanisandmodifiedbyWeber,anditwaspopularizedbytheAOduringatimewhenmalleolarfractureswereincreasinglytreatedbyoperativereductionandfixationratherthanbyclosedreduction.FractureswerecategorizedintoA,B,andCbasedonthelevelofthefibularfracture,withAfracturesbelowthelevelofthedistaltibial

fibularsyndesmosis,Bfracturesatthelevelofthesyndesmosis,andCfracturesabovethesyndesmosis.

ThissimpleclassificationprovidedinitialguidelinesforsurgicaltreatmentbecauseAfracturesfrequentlydonotrequiresurgicaltreatment,Bfracturesaretreatedbystabilizationofthelateralmalleolus,andCfracturesrequiresyndesmosisfixationinadditiontostabilizationofthelateralmalleolus.Thisclassificationwasattractiveforitssimplicityandbecauseitguidedtreatment.治疗

目标：骨折解剖复位，恢复关节功能。手术适应症：

1保守治疗失败

2有移位或不稳定的双踝骨折，且有距骨脱位或踝穴增宽超过1－2mm。

3后踝骨折涉及关节面超过25％，且关节面的移位超过2mm。

4垂直压缩型骨折

5开放骨折单独外踝骨折1多为旋后－外旋2度或AO的B1型2多数保守治疗3是否手术有争议

Bauer（1985）认为保守治疗的功能优良为94－98％。

Yue（1980）认为旋后－外旋2度的手术治疗的结果并不优于保守治疗。单独内踝骨折1多为旋前－外旋或旋前－外展的1度损伤。2多保守治疗（无移位的）3有移位的使用松质骨螺钉固定下胫腓联合损伤固定的指征内固定的选择固定时踝关节的位置内固定物是否取出固定的指征

内踝三角韧带损伤，腓骨骨折高于踝关节水平间隙上方3cm。下胫腓联合损伤合并腓骨近端骨折，如Maisonneuve骨折陈旧的下胫腓分离内固定的选择

公认的是使用螺钉固定。一般均使用3.5-4.5mm的皮质骨螺钉。有学者认为必要时可使用2枚。螺钉的使用1螺钉的位置－McBryde（1997）认为胫距关节间隙上方2cm是最佳位置。2螺钉方向－平行胫距关节面且向前倾斜25－30度。3是否使用拉力螺钉－不使用。下胫腓螺钉的主要目的是维持下胫腓联合的正常位置，加压易导致