跟骨关节内骨折的手术治疗课件

跟骨关节内骨折的手术治疗TheSurgicaltreatmentofintraarticularcalcanealfractures ChengduuniversityoftraditionalChinesemedicine吴晓均薛景景WuxiaojunXuejingjing2011 08 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 Fracturesofcalcaneusareoffractureoftarsalbones60 65 and2 allfractures Homograftingaccountedfor70 80 ofallcalcanealfractures Inthispapercontroversiesinvolvereferstospreadfromthejointafterwithbonefractures 跟骨骨折的后遗症 距下关节痛 Thepainofsubtalarjoint 腓骨长肌腱鞘炎 Thetenosynovitisofperoneuslongus 骨刺 Bonyspur 跟骰关节炎 Thearthritiscalcaneocuboidjoint 神经卡压 Nervecompressionsyndromessle 跟骨解剖 跟骨解剖 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 MechanismofInjury HighfelldownWithboneissuperloadshearforceandcompressionforcefromthebonethatwithbonefractures embeddedinlinewithboneonthebottomfirst followedwithbonejointsurfaceappearafterthecollapse withboneinternallygeneratedpowerofmeetanemergency andalongthecoronalconduction fracturetothesideandseparationandtheformationofgrandoflateralwall sothattheshorterwithboneiswide 跟骨骨折的分类 不波及跟距关节的跟骨骨折Externalarticularcalcanealfractures波及跟距关节的跟骨骨折Intraarticularcalcanealfractures 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Longitudinalfractureofcalcaneus跟骨结节水平骨折Levelfractureofcalcaneus跟骨截距突骨折Fractureofcalcaneusinterceptaxon跟骨前端骨折Fractureofthefrontofcalcaneus接近跟距关节的骨折Closetothecoronalfractures 波及跟距关节的跟骨骨折约占跟骨骨折的70 80 SandersCT分型 型 无移位关节内骨折Intraarticularcalcanealfractureswithoutdisplacement 型 有移位的2部分骨折Twopartsfracturewithdisplacement 型 有移位的3部分骨折Threepartsfracturewithdisplacement 型 有移位的4部分骨折Fourpartsfracturewithdisplacement SandersCT分型 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Sanders 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 b hler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 Surgicalindicationsofintraarticularcalcanealfractures Calcanealarticularsurfaceaftermorethan2mmdisplacedintra articularfractures themainstreamviewismorethanSanderstypefracturewithclearindicationsofelectiveoperation Calcanealshortenedobviously Calcaneusincreasedwidthisgreaterthanorequalto1cm Calcanealheightlowerthan1 5cm B hlerislessthanorequalto15 Gissaneanglelessthanorequalto90oorgreaterthanorequalto130 Aroundwithcalcaneusjointdislocationorsubluxation Calcaneusexternalexpansioneffectoflateralmalleolusperonealtendinousactivities CalcanealaxialX rayshowsvarusangulationgreaterthanorequalto5 valgusisgreaterthanorequalto10 跟骨骨折的治疗目的Therapeuticpurposesofintraarticularcalcanealfractures 恢复距下关节后关节面的外形Restorationofthesubtalarjointposteriorarticularsurfaceshape 恢复跟骨的高度 b hler角 Restorationofcalcanealheight 恢复跟骨的宽度Restorationofcalcanealwidth 对腓骨肌腱走行的腓骨下间隙减压Theperonealtendonwalkingthefibuladecompression恢复跟骨结节的内翻对线Restorationofcalcanealvarusalignment 手术时机 Operationtime 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 Generalclosedcalcanealfractureoperationuntilinjuryafter7 10days theskinfolds softtissueconditions Iftheswellingissevereoraccompaniedbyvesicular operationtimeshouldalsobeanappropriateextension butgenerallynotmorethan3weeks 手术体位 Operationposition 侧卧位 患肢在上 Lateralposition andtheaffectedlimbonthetop 患肢大腿根部扎止血带 TourniquetIntheproximalthighinjury 跟骨外侧和髂骨部充分显露Fullyexposedoutsideandiliacboneofcalcaneus 术野碘伏消毒前常规酒精脱脂 IntheoperationareawithIodophordisinfectionwithalcoholtoskim 手术入路 Operationapproach 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 lateraloperationapproachisthemostpopularandmostoftheclinicalapplicationofapproach itcanclearlyshowlater articularsurfaceandcalcaneocuboidarticularsurfacefractures andtothedisplacedfracturefragments especiallyaftertheshift collapseofthearticularsurfacefractureseffectivelyreset andimplantplacementisconvenient spacelarge 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 Operationincisionanddisplaytechnology Theincisionisroughlytheshapeof L CutbranchesinthefibulaandtheAchillestendondownwardbetweenthehorizontalsupport incisionattheheeloftheplantarsideofthelateralcalcanealskinandskinbetweentransverseincision cutonthesupportandalowersupportcornernotatrightangles butasanarc Payattentiontotheprotectionofthesuralnerveandperonealtendinous Calcaneusoffull thicknessincisionofskinandsubcutaneoustissueuntilthesubperiosteal notsubcutaneousdissectionwithsharpknifedirectlyagainstthecalcaneallateralwallperiostealstripping strippingthesurfacelengthfromthecalcanealfibularmusclesupportbeltandcalcaneofiblarligament calcanealarticularsurfaceisrevealed Thewholeliftflap withthere2mmKirschnerneedlesarerespectivelyinsertedintothefrontandrearofthetalusfibulaandcuboid andbendingsofttissueretractor revealtheoperationfield Openandrevealingtheprocessdoesnotuseelectricknifeincision forobviousperforatorvesselsweregivenasinglebar 凿除部分外侧骨质Biteoffpartofthelateralcalcanealbone 有利于显露距下关节面Toshowfromthearticularsurface 有利于跟骨宽度的恢复Isconducivetotherestorationofcalcanealwidth 凿除骨块可用于植骨Biteexceptboneblockscanbeusedforbonegrafting 缝合时伤口张力降低Reducesutureoperationincisiontension 对跟骨的负重功能无明显影响Calcanealweight bearingfunctionhadnosignificanteffecton 恢复关节的关系Restorationofthearticularanatomy 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Pokingcollapseorreversibleposteriorarticularsurface andtorestorethetalararticularsurfaceconformityandthecontactareaforthestandard参考术前X线片和CT片 充分结合术中直视所见 ReferenceoperationbeforetheX rayfilmandCTfilm fullyintegratedoperationdirectlysee 复位后以1mm细克氏针临时固定关节软骨下骨质Fracturereduction using1mmKirschnertemporaryfixationofarticularcartilagebone 恢复Gissane角和B hler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 Posteriorarticularsurfaceforgoodafterreset usingKirschnerwirebackwardpullingdownthecalcanealtuberosity Gissane角正常值 123 8 8 7 ThenormalvalueofGissaneangle 123 8 8 7 B hler角 正常值20o 40oThenormalvalueofB hlerangle 20o 40o 恢复跟骨宽度Restorationofcalcanealwidth 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 Elevationoftheposteriorarticularsurface thebroadeningofcalcanealrelativepressreset exceptwhennecessarytobiteoutwardbulgingouterwall correctingthecalcanealvalgusangulation 恢复跟骨高度Restorationofcalcanealheight 关键在于后关节面的抬高Thekeyliesintheposteriorarticularsurfaceelevation 是否植骨 有争论 Bonegraft Underdebate 多数人认为常规植骨Mostpeoplethinktobonegrafting 后关节面可即刻获得支撑力Posteriorarticularsurfacecaninstantlygainsupport减少内固定承受的应力Reductionfixationunderstress有利于骨折愈合Thebonefracturehealing采用自体髂骨或同种异体骨植骨 Theiliaccrestautograftorallograft 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 Sufficientbonegraftbutnottootight soastoavoidthecalcaneusistoowideorcompressedcalcaneuscancellousboneleadtoiatrogenicfracture 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 Internalfixation Thecalcaneallateralwallfixedtothecalcaneusreconstructionplate special shapedplate calcanealanatomicplate accordingtotheintraoperativesituationofchoice SustentaculumTali posteriorarticularsurfacebelow thecalcanealtuberosityandcalcanealprotrusiondorsalhalfoftheboneisrelativelydense isscrewedintothescrewforfracturefixationidealsite ItisveryimportanttothesustentaculumTalifixed fixedscrewdirectiontomedialmalleolus2 5cmsustentaculumTalilandmarks shouldchoosecorticalbonescrews theremainingfixedpointsavailablecancellousbonescrew Platescrewholeswillnotfullyfinished thegeneraluseof5piecesofit Screwsoundinglengthshouldbeappropriatelyshortened inordertoavoidthecalcaneuswidthrecoveryafterthescrewprotrudesfromthesubcutaneouslong 切口处理Operationincisionprocessing 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 Anorthopedicdrainagefromthetopflapsholespokedouttheother mustdrainage calcanea