跟骨关节内骨折的手术治疗

null跟骨关节内骨折的手术治疗 The Surgical treatment of intra articular calcaneal fractures跟骨关节内骨折的手术治疗 The Surgical treatment of intra articular calcaneal fractures Chengdu university of traditional Chinese medicine 吴晓均 薛景景 Wu xiaojun Xue jingjing 2011-08概况概况跟骨骨折占跗骨骨折60%—65%，所有骨折2%。关节内骨折占所有跟骨骨折的70%—80%。本文中的跟骨关节内骨折是指波及跟骨后距关节面的骨折。 Fractures of calcaneus are of fracture of tarsal bones 60%-65%, and 2% all fractures. Homografting accounted for 70%-80% of all calcaneal fractures.In this paper controversies involve refers to spread from the joint after with bone fractures. 跟骨骨折的后遗症跟骨骨折的后遗症距下关节痛 (The pain of subtalar joint) 腓骨长肌腱鞘炎(The tenosynovitis of peroneus longus ) 骨刺(Bony spur) 跟骰关节炎(The arthritis calcaneocuboid joint ) 神经卡压(Nerve compression syndromes sle )nullnull 跟骨解剖 跟骨解剖跟骨解剖跟骨解剖受伤机制受伤机制多由高处跌坠。 跟骨受到超强载荷时剪切力和压缩力使距骨嵌入跟骨，骨折线首先在跟骨底部展开，继之出现跟骨后关节面塌陷，跟骨内部产生应变力，沿冠状面传导，使骨折向两侧分离而形成侧壁膨隆，从而使跟骨变短变宽。Mechanism of Injury Mechanism of Injury High fell down With bone is super load shear force and compression force from the bone that with bone fractures, embedded in line with bone on the bottom first, followed with bone joint surface appear after the collapse, with bone internally generated power of meet an emergency, and along the coronal conduction, fracture to the side and separation and the formation of grand of lateral wall, so that the shorter with bone is wide.跟骨骨折的分类跟骨骨折的分类不波及跟距关节的跟骨骨折 External articular calcaneal fractures 波及跟距关节的跟骨骨折 Intra articular calcaneal fractures.不波及跟距关节的跟骨骨折约占跟距骨折的20%—30%不波及跟距关节的跟骨骨折约占跟距骨折的20%—30%分类： 跟骨结节纵行骨折 Longitudinal fracture of calcaneus 跟骨结节水平骨折 Level fracture of calcaneus 跟骨截距突骨折 Fracture of calcaneus intercept axon 跟骨前端骨折 Fracture of the front of calcaneus 接近跟距关节的骨折 Close to the coronal fractures 波及跟距关节的跟骨骨折约占跟骨骨折的70%—80%波及跟距关节的跟骨骨折约占跟骨骨折的70%—80%Sanders CT分型： Ⅰ型：无移位关节内骨折 Intra articular calcaneal fractures without displacement Ⅱ型：有移位的2部分骨折 Two parts fracture with displacement Ⅲ型：有移位的3部分骨折 Three parts fracture with displacement Ⅳ型：有移位的4部分骨折 Four parts fracture with displacement Sanders CT分型Sanders CT分型关节内跟骨骨折的手术适应症关节内跟骨骨折的手术适应症 1、跟骨后关节面超过2mm移位的 关节内骨折，目前较主流的观点 是SandersⅡ型以上骨折即有明确 的择期手术指征。 2、跟骨长度短缩明显 。 3、跟骨宽度增加大于等于1cm。 4、跟骨高度降低超过1.5cm。 5、böhler小于等于15o。 6、Gissane角小于等于90o或大于等于130o。 7、伴有跟骨周围关节的脱位或半脱位。 8、跟骨外膨明显影响 外踝部腓骨长短肌腱的活动。 9、跟骨轴位X线示内翻畸形成角大于等于5o，外翻大于等于10o。Surgical indications of intra articular calcaneal fracturesSurgical indications of intra articular calcaneal fracturesCalcaneal articular surface after more than 2mm displaced intra-articular fractures, the mainstream view is more than Sanders type fracture with clear indications of elective operation. Calcaneal shortened obviously. Calcaneus increased width is greater than or equal to 1cm. Calcaneal height lower than 1.5cm. Böhler is less than or equal to 15°. Gissane angle less than or equal to 90o or greater than or equal to 130°. Around with calcaneus joint dislocation or subluxation. Calcaneus external expansion effect of lateral malleolus peroneal tendinous activities. Calcaneal axial X-ray shows varus angulation greater than or equal to 5°, valgus is greater than or equal to 10°.跟骨骨折的治疗目的 The rapeutic purposes of intra articular calcaneal fractures跟骨骨折的治疗目的 The rapeutic purposes of intra articular calcaneal fractures恢复距下关节后关节面的外形 Restoration of the subtalar joint posterior articular surface shape. 恢复跟骨的高度（böhler角） Restoration of calcaneal height. 恢复跟骨的宽度 Restoration of calcaneal width. 对腓骨肌腱走行的腓骨下间隙减压 The peroneal tendon walking the fibula decompression 恢复跟骨结节的内翻对线 Restoration of calcaneal varus alignment. 手术时机(Operation time)手术时机(Operation time) 一般闭合性跟骨骨折手术推迟到伤后7-10天，此时皮肤出现皱褶，软组织条件较好。若患肢肿胀严重或伴有水疱，则手术时间还应适当延期，但一般不超过3周。 General closed calcaneal fracture operation until injury after 7-10 days, the skin folds, soft tissue conditions. If the swelling is severe or accompanied by vesicular, operation time should also be an appropriate extension, but generally not more than 3 weeks.手术体位(Operation position)手术体位(Operation position)侧卧位，患肢在上。 Lateral position,and the affected limb on the top. 患肢大腿根部 扎止血带。 Tourniquet In the proximal thigh injury. 跟骨外侧和髂骨部充分显露 Fully exposed outside and iliac bone of calcaneus. 术野碘伏消毒前常规酒精脱脂。 In the operation area with Iodophor disinfection with alcohol to skim.手术入路 (Operation approach)手术入路 (Operation approach) 外侧入路是目前临床最流行和应用最多的入路，能清楚显露后、中关节面及跟骰关节面骨折情况，并能对移位的骨折块，特别是移位、塌陷的后关节面骨折进行有效的复位，并且内置物放置方便，空间大。 Currently, lateral operation approach is the most popular and most of the clinical application of approach, it can clearly show later, articular surface and calcaneocuboid articular surface fractures, and to the displaced fracture fragments, especially after the shift, collapse of the articular surface fractures effectively reset, and implant placement is convenient, space large.切开及显露技术切开及显露技术 切口大体呈“L”形。切口上支在腓骨与跟腱之间向下；切口水平支在足跟跖侧皮肤与跟骨外侧皮肤之间横形切开（此部皮肤软组织分属腓动脉和胫后动脉分支供血），切口上支和下支转角处勿成直角，而应成弧形。 注意保护腓肠神经和腓骨长短肌腱 跟骨部全层切开皮肤皮下组织直到骨膜下，勿行皮下剥离，用锐刀直接紧贴跟骨外侧壁剥离骨膜，自跟骨表面剥离腓骨长短肌支持带和跟腓韧带，显露跟骨上端关节面。 整块掀起皮瓣，用3枚2mm克式针分别插入腓骨前后方的距骨内和骰骨，并折弯将软组织牵开，显露手术野。 切开和显露过程不使用电刀，对于切口内明显的穿支血管给予单扎。 Operation incision and display technologyOperation incision and display technologyThe incision is roughly the shape of "L". Cut branches in the fibula and the Achilles tendon downward between the horizontal support; incision at the heel of the plantar side of the lateral calcaneal skin and skin between transverse incision, cut on the support and a lower support corner not at right angles, but as an arc. Pay attention to the protection of the sural nerve and peroneal tendinous. Calcaneus of full-thickness incision of skin and subcutaneous tissue until the subperiosteal, not subcutaneous dissection with sharp knife directly against the calcaneal lateral wall periosteal stripping, stripping the surface length from the calcaneal fibular muscle support belt and calcaneofiblar ligament, calcaneal articular surface is revealed. The whole lift flap, with there 2mm Kirschner needles are respectively inserted into the front and rear of the talus fibula and cuboid, and bending soft tissue retractor, reveal the operation field. Open and revealing the process does not use electric knife incision, for obvious perforator vessels were given a single bar.凿除部分外侧骨质 Bite off part of the lateral calcaneal bone凿除部分外侧骨质 Bite off part of the lateral calcaneal bone有利于显露距下关节面 To show from the articular surface. 有利于跟骨宽度的恢复 Is conducive to the restoration of calcaneal width. 凿除骨块可用于植骨 Bite except bone blocks can be used for bone grafting. 缝合时伤口张力降低 Reduce suture operation incision tension. 对跟骨的负重功能无明显影响 Calcaneal weight-bearing function had no significant effect on. 恢复关节的关系 Restoration of the articular anatomy恢复关节的关系 Restoration of the articular anatomy 撬拨塌陷或翻转的后关节面，以恢复与距骨关节面吻合度及接触面积为标准 Poking collapse or reversible posterior articular surface, and to restore the talar articular surface conformity and the contact area for the standard 参考术前X线片和CT片，充分结合术中直视所见。Reference operation before the X-ray film and CT film, fully integrated operation directly see. 复位后以1mm细克氏针临时固定关节软骨下骨质 Fracture reduction, using 1mm Kirschner temporary fixation of articular cartilage bone.恢复Gissane角和Böhler角恢复Gissane角和Böhler角 在后关节面良好复位后用克式钢针向后向下牵拉跟骨结节。Posterior articular surface for good after reset, using Kirschner wire backward pulling down the calcaneal tuberosity. Gissane角正常值：12 3 .8°± 8.7° The normal value of Gissane angle:12 3 .8°± 8.7° Böhler角：正常值20o-40o The normal value of Böhler angle: 20o-40o恢复跟骨宽度 Restoration of calcaneal width.恢复跟骨宽度 Restoration of calcaneal width. 抬高后关节面后，将增宽跟骨相对挤压复位，必要时凿除部分向外膨出的外侧壁，纠正跟骨的外翻成角。 Elevation of the posterior articular surface, the broadening of calcaneal relative press reset, except when necessary to bite outward bulging outer wall, correcting the calcaneal valgus angulation. null恢复跟骨高度 Restoration of calcaneal height. 关键在于后关节面的抬高 The key lies in the posterior articular surface elevation. 是否植骨？有争论。 Bone graft? Under debate.是否植骨？有争论。 Bone graft? Under debate. 多数人认为常规植骨 Most people think to bone grafting. 后关节面可即刻获得支撑力 Posterior articular surface can instantly gain support 减少内固定承受的应力 Reduction fixation under stress 有利于骨折愈合 The bone fracture healing 采用自体髂骨或同种异体骨植骨。 The iliac crest autograft or allograft. 充分植骨但不能过多过紧，以免跟骨过宽或压缩跟骨松质骨导致医源性骨折。 Sufficient bone graft but not too tight, so as to avoid the calcaneus is too wide or compressed calcaneus cancellous bone lead to iatrogenic fracture. 固定固定 跟骨外侧壁的固定有跟骨重建钢板、异型钢板、跟骨解剖钢板等，根据术中情况选用. 载距突、后关节面下方、跟骨结节及跟骨前突背侧半部分的骨质相对较为致密，是拧入螺钉进行骨折固定的理想部位。 载距突的固定十分重要，固定时螺钉方向指向内踝尖下2.5cm载距突的体表标志，应选用皮质骨螺钉，其余固定点可用松质骨螺钉。 钢板螺钉孔不必全打完，一般使用5枚就可以了。 螺钉测深的长度应适当缩短，以避免跟骨宽度恢复后螺钉过长凸出于皮下。 Internal fixationInternal fixationThe calcaneal lateral wall fixed to the calcaneus reconstruction plate, special-shaped plate, calcaneal anatomic plate, according to the intraoperative situation of choice. Sustentaculum Tali, posterior articular surface below, the calcaneal tuberosity and calcaneal protrusion dorsal half of the bone is relatively dense, is screwed into the screw for fracture fixation ideal site. It is very important to the sustentaculum Tali fixed, fixed screw direction to medial malleolus 2.5cm sustentaculum Tali landmarks, should choose cortical bone screws, the remaining fixed points available cancellous bone screw. Plate screw holes will not fully finished, the general use of 5 pieces of it. Screw sounding length should be appropriately shortened, in order to avoid the calcaneus width recovery after the screw protrudes from the subcutaneous long. 切口处理Operation incision processing.切口处理Operation incision processing. 安骨科引流管从上方皮瓣另戳孔引出（必须引流，跟骨术后出血量较大）。术后24小时内拔管。 An orthopedic drainage from the top flaps holes poked out the other ( must drainage, calcaneal on postoperative blood loss is greater). After 24 hours of extubation. 切口转角处皮肤采用褥式缝合法。 Skin incision corner with mattress suture. 加压包扎踝关节于轻度外翻位，以减少切口张力。Compression bandage ankle to mild valgus position, in order to reduce incision tension. 回病房后抬高患肢，切口间断冰敷6—8小时。 Back to the ward after raising the affected limb, incision intermittent ice 6 - 8 hours. 术后处理The treatment after operation术后处理The treatment after operation 常规抗感染3—5天 Conventional anti infection in 3 - 5 days 术后48小时开始进行小范围膝、足趾关节的主动、被动练习。 Operation is complete after 48 h, started the knee, toe joint small active, passive exercise. 术后2周拆线 Suture removal after 2 weeks of operation 术后2—3周挟拐下地，但禁止患肢负重 After 2 - 3 weeks with the left, but no limb weight-bearing 术后8—12周逐步负重 After 8 to 12 weeks of progressive weight bearing 总结 Summary总结 Summary手术技术还不成熟，仍处于学习的过程 Operation technology is not mature, still in the learning process 部分病例复位，固定困难。 In some cases the fracture reduction, fixation is difficult. 术后疗效有待提高。 Postoperative efficacy remains to be improved. 病 例 1病 例 1 病 例 2病 例 2病 例 3病 例 3病例4病例4null