张候Z-H骨折

张候骨折（Z-H骨折）胫骨下1/3螺旋骨折合并后踝骨折,段彪2016.8.15,定义,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,病因胫骨骨折,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,病因后踝骨折,后踝的骨小梁纵向排列，骨折线常与胫骨纵轴平行,Z-H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,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2mm,IV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,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%,漏诊原因,对胫骨下1 /3 螺旋形骨折合并后踝骨折的认识不够,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,一些医院X 线片的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的重叠,尤其是合并腓骨远段骨折时,更加难以分辨,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 radiographs are often insufcient for detecting posterior malleolus fractures in conjunction with ipsilateral distal third diaphyseal tibia fractures. Using a preoperative CT protocol for tibial shaft fractures can signicantly improve the ability to diagnose associated intra-articular fractures 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 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,I度,II度,III度,IV度,后踝可不予特殊处理,手术时密切注意并保护后踝，髓内钉不要过长、螺钉不要打入骨折线 ，必要时后踝行克氏针或拉力螺钉固定,手术时应首先固定后踝骨折，以防操作中后踝骨折块发生移位,后踝骨折块应予复位固定,恢复踝关节的稳定性和完整性,胫骨远端骨折合并后踝骨折，术中应先固定后踝美国学者 Harish Kempegowda 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，作者建议先固定后踝，再行髓内钉固定胫骨,those treated with a mode of fixation other than an intramedullary nail for a tibial shaft fracture were excluded from the study.,Outcomes 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,梁敏玲，女，50岁，入院日期：2015.10.6主诉：扭伤致右小腿肿痛，