Pilon骨折ppt课件

.,Pilon骨折,2010级骨伤专业叶青谢君,.,定义:pilon骨折是指累及胫距关节面的胫骨远端骨折。胫骨Pilon骨折目前尚没有明确的定义，一般是指胫骨远端1/3波及胫距关节面的骨折，胫骨远端关节面严重粉碎，骨缺损及远端松质骨压缩。常合并有腓骨下段骨折（约75%85%)和严重软组织损伤。,.,Definition：Pilonfracturereferstodistaltibiafractureswhichinvolvetibia-astragalusarticularsurface.Pilonfracturehaventgotcleardefinitionyet,itusuallyreferstothirddistaltibiafracturesspreadfromthejoint.Thedistaltibialarticularsurfacealwaysseriousshattered,bonedefectandremotecancellousbonecompression.ItusuallyAssociatedwiththelowerpartoffibulafractures(about75%85%)andserioussofttissueinjury.,.,名称来源：1911年首先由法国放射学家Destotti提出“tibialpilon”一词，他把胫骨远端干骺端的形状描述为像药剂师的杵棒。胫骨远端关节面形似天花板,1950年Bonin称之为“tibialplatfond”，因此pilon骨折又称为platfond骨折。,.,Definitionorigin:In1911,theFrenchradiologistDestottifirstlyputforwardtheword-tibialpilon“.Hedescribedtheshapeofdistaltibiaasthepharmacistspestle(pilon).Thedistaltibialarticularsurfaceisalsolookslikeceiling;In1950,bonincalledit“tibialplatfond”,sopilonfracturecanbecalledPlatfondfracture.,.,损伤机制：胫骨Pilon骨折最常发生于高处坠落、车祸骤停、滑雪或绊脚前摔。胫骨轴向暴力或下肢的扭转暴力是胫骨远端关节面骨折的主要原因。两种不同的损伤机制导致Pilon骨折，其预后亦不同,受伤时踝关节的位置与骨折类型密切相关.,.,Injuremechanism:TibialPilonfracturesoccurmostofteninthefall,crasharrest,skiingorstumblingbeforethefall.Axialtibialviolenceortorsionviolenceoflowerextremityarethemainreasonfordistaltibialarticularsurfacefractures.TwodifferentmechanismsofinjuryleadingtodifferentprognosisofPilonfracture.Thepositionofanklejointwhenithurtsandthetypeoffracturearecloselyrelated.,.,骨折高度不稳定和关节软骨损伤严重。治疗难度大，并发症多，致残率高，是最具挑战性的骨科难题之一。_内容丰富点。列出几点.胫骨远端关节面严重粉碎，骨缺损及远端松质骨压缩。常合并有腓骨下段骨折（约75%85%)和严重软组织损伤,骨折特征,.,Fracturecharacteristic:Itisahighlyunstablefracture,andhaveseverearticularcartilagedamage.Treatmentisdifficult,withmanycomplications,highdisabilityrate,anditisoneofthemostchallengingorthopaedicproblems.,.,骨折分型：骨折分型的目的主要还是在于如何指导治疗及提示预后情况。1969年Ruedi和Augower根据关节面和干骺端的移位及粉碎程度，将Pilon骨折分为3型，这种分型的意义在于强调关节面的损伤程度。,.,Fractureclassify:Themainpurposeoffractureclassificationistoguidetreatmentandpromptprognosis.In1969RuediandAugowerdividedPilonfractureinto3typesaccordingtothearticularsurfaceandmetaphysealdisplacementandcrushingdegree,themeaningofthistypeliesinemphasizingthearticularsurfacedamage.,.,Ruedi-Allgower分类系统型:经关节面的胫骨远端骨折，较小的移位;型:明显的关节面移位而粉碎程度较小;型:关节面粉碎移位及粉碎程度较严重。这种分型临床常用。,.,TheRuedi-Allgowerclassificationsystem:Typeone:Thearticularsurfacefracturesofdistaltibia,alittledisplacement;Typetwo:Theobviousarticularsurfaceshiftandcrushlesserdegree;Typethree:Articularsurfacecrushingshiftandthedegreeisserious.Thistypeofcommonlyusedclinical.,.,诊断:根据病史、症状、体征，结合X片、CT等影像学检查，诊断不难，注意血管、神经等软组织的损伤，常见胫骨内侧、前侧开放性及潜在开放性损伤，认真查体，注意勿遗漏身体其他部位的损伤（脊柱骨折、腓骨上段骨折等）。,.,Diagnosis:Accordingtothemedicalhistory,symptoms,signs,combinedwithX,CTimagings,diagnosisisnotdifficult,payattentiontovascular,nerve,softtissueinjury,Theinsideoftibial,anterioropenandpotentialopeninjuryarecommon,carefullycheckthebody.Payattentionnottomisstheotherpartinjuryofthebody(spinalfractures,upperfibulafractureetc).,.,治疗,（1）非手术治疗：适应于型无移位骨折、全身情况较差不能耐受手术者、以及为延期手术做准备的治疗。主要有手法复位石膏外固定、跟骨牵引等。,.,Treatment,(1)Nonoperationtreatment:AdaptedtothetypeIfractureswithoutdisplacement,poorgeneralconditionwhichcannottolerateoperation,aswellasthetreatmentforthedeferredoperation.Mainlywithmanipulativereductionandplasterexternalfixation,calcanealtraction,closedpinningfixation,etc.,.,（2）手术治疗：手术指征：、型开放性骨折，骨折明显移位或嵌插、缺损、伴有神经血管损伤、轴向对线不良、关节面骨折移位大于2mm者，均需积极行手术治疗。,.,Operationtreatment:Operationindications:TpreII,typeIIIopenfractures,fracturewasobviouslydisplacedorimpacted,defect,accompaniedbythenerveandvascularinjury,theaxialmalalignment,articularsurfacefracturedisplacementisgreaterthan2mm,theseallshouldbeactivelytreatedwithsurgicaloperation.,.,手术原则：低能量损伤的pilon骨折积极行切开复位内固定术（ORIF）；高能量损伤者，采取有限内固定和外固定结合的治疗手段。目前主张“生物学”原则：强调细致的软组织暴露，骨折块的有限剥离，间接复位，稳定固定后早期活动和晚期负重等.治疗目的可归纳为“3P”，即保护骨与软组织活力、进行关节面的解剖复位、提供满足踝关节早期活动的固定。,.,Operationprinciple:LowenergydamageofPilonfracturestreatedwithopenreductionandinternalfixationofpositive(ORIF);highenergyinjury,takelimitedinternalfixationandexternalfixationcombinedtreatment.Currentlyadvocated“biology”principle:emphasizingmeticuloussofttissueexposure,fractureblockfinitestrip,indirectreduction,doearlyexerciseafterstablefixationandlateweightbearing,etc.Treatmentgoalscanbesummarizedas“3P”,theprotectionofboneandsofttissueviability(preserve),anatomicalreductionofthearticularsurface(perform),providefixationswhichcansatisfyearlymotionoftheanklejoint(provide).,.,手术时机：1、开放性骨折就诊时间早或出现筋膜间室综合征的患者，均应行急诊手术处理。对于污染严重的（先清创）、就诊时间晚、肿胀严重、软组织条件差的开放性骨折主张先行跟骨牵引、石膏托固定、或超关节外固定架临时固定等治疗，待肿胀消退，水泡愈合后行二期处理。2、对于闭合性骨折的手术时机，目前还存在较大的争议，大多数人倾向于认为除软组织条件差的闭合性骨折需行延期手术外，一般应于伤后8-10小时之内，肢体肿胀不甚严重，无明显水泡形成之前急诊手术为妥，有利于骨折复位。张力较高及皮肤缺损者，可留待创面行二期处理。这个应该放在开放性骨折后面,.,Operationtime:Patientofopenfracturestoseeadoctorearlyorturnupcompartmentsyndrome,urgentoperationtreatmentisnecessary.Fortheseriouspollution(firstdebridement),treatmenttimeoflate,severesofttissueswelling,poorconditionsofopenfractureofcalcaneustractionthatgoaheadoftherest,plastersupport,oroverarticularexternalfixatorfortreatmentoftemporaryfixed,afterswelling,blistershealed,dothesecondaryperiodoftreatment.Foraclosedfractureoftheoperationopportunity,atpresentstillexistscontroversy,Iagreewiththat,inadditiontopoorconditionsintheclosedfracturesshoulddodelayedoperation,generallymostfractureshoulddourgentsurgryin8-10hoursafterinjurywhentheswellingofalimbisnotseriousandnoblisterformation.Thisfacilitatesfracturereset.Highertensionandskindefectwound,maybeleftforsecondarytreatment.,.,手术方法：型：有时为了避免非手术治疗可能发生的骨折移位缩短外固定的时间，采用有限切开简单内固定加石膏外固定,闭合复位后经皮空心螺钉固定术,微创经皮钢板接骨术(MIPPO技术)。,.,Operationmethod:TypeI:sometimesinordertoavoidnonoperationtreatmentofpossibledisplacementoffractureandshortenthetimeofexternalfixation,wechooselimitedopensimpleinternalfixationcombinedwithexternalfixationofplaster.Afterclosedreductionandpercutaneoushollowscrewfixation,minimallyinvasivepercutaneousplateosteosynthesis(MIPPOtechnology);,.,型：关节面虽有移位，但并未粉碎和压缩，以有限切开复位内固定为宜。近年来有主张关节镜结合环形外固定架的治疗和关节镜辅助下复位经皮螺钉内固定术。,.,TypeII:Thearticularsurfacedisplaced,butnotcrushedandcompressed,limitedopenreductionandinternalfixationisappropriate.Inrecentyears,someonehaveadvocatedthearthroscopycombinedwithcircularexternalfixation;Arthroscopicassistedreductionandpercutaneousscrewfixationhavealsobeenused.,.,型：闭合性的高度不稳定骨折，关节面严重粉碎者，行经典的切开复位内固定术加植骨术。严重粉碎已无解剖复位可能的高能量损伤、大块骨缺损、严重软组织损伤、开放性骨折的Gustilo、型患者行有限的切开复位内固定结合外固定支架是较好的选择。也有主张行分期重建内固定的方法，先固定腓骨，同时使用外固定支架保持肢体的长度和力线，经过1021d的中间期，使软组织的条件得以充分改善以减少术后软组织的并发症；再对胫骨远端的关节面进行标准的切开复位内固定。,.,TypeIII:Closedhighlyunstablefractures,comminutedarticularsurface,chooseclassicopenreductionwithinternalfixationandbonegraft.Severecomminutionhavenoanatomicalreductionpotentialofhighenergyinjury,massivebonedefects,severesofttissueinjury,openfractureoftheGustiloII,typeIIIweretreatedwithlimitedinternalfixationcombinedwithexternalfixationisagoodchoice.Somebodyclaimsreconstructionmethodsoffixationbystages,fixfibulafirstly,atthesametimeusingexternalfixationtomaintainlimblengthandlineofforce,after10-21dintermediateperiod,sothatthesofttissueconditionscanbefullyimprovedtoreducepostoperativesofttissuecomplications;then,thestandardopenreductionandinternalfixationareusedinthedistaltibialarticularsurface.,.,关节融合术和关节置换术：由于Pilon骨折的患者不是都能达到完全的解剖复位，即使可以解剖复位，由于骨折后关节软骨下骨发生坏死、塌陷变化，也就不可避免创伤性关节炎的发生。因而踝关节融合术、关节置换术的时机选择,应根据具体情况而定。一般宜在伤后12年内根据症状、体征、X线表现及患者要求行融合术或置换术。,.,Arthrodesisandanklejointreplacement:BecausenotallofPilonfracturepatientscanachievecompleteanatomicreduction,evencanachieveanatomicreduction,duetoarticularsubchondralbonenecrosisandcollapseafterfracture,itisinevitablethattheoccurrenceoftraumaticosteoarthritis.Thusthearthrodesisandreplacementoftheanklejointtiming,shouldbebasedonthespecificcircumstancesofthecase.Generallyafterinjuryin1-2yearsaccordingtothesymptoms,signs,Xrayperformanceandpatientsrequirefusionandreplacementsurgery.,.,总之：从文献报道的有关Pilon骨折治疗的临床研究来看,制定合理而完善的术前计划、有限内固定结合外固定治疗以及根据软组织损伤情况分期治疗,降低了软组织损伤导致的并发症发生率，已显示出其明显的优越性。同时，治疗过程中踝关节早期功能锻炼，避免过长时间的外固定，能最大限度地减少针道感染、关节僵硬等并发症。,.,Inconclusion,fromtheliteraturereportsaboutPilonclinicalstudyontreatmentofview,establishreasonableandperfectpreoperativeplanning,limitedinternalfixationcombinedwithexternalfixationinthetreatmentofsofttissueinjuryandaccordingtothestagingoftreatment,havereducedthesofttissuedamagewhichleadstothecomplicationrate,andobviousadvantageshavebeenproved.Atthesametime,duringthetreatmentofanklejointandearlyfunctionalexercise,avoidprolongedexternalfixation,canminimizethepintractinfection,jointstiffnessandothercomplications.,.,切开复位内固定原则：（1）恢复腓骨长度并做内固定;（2）力求解剖复位，重建胫骨远端关节面（关键骨折块、Chaput结节等）;（3）干骺端骨缺损处植骨（支撑关节面、填补空缺、刺激成骨、促进骨折愈合）;（4）胫骨内侧支撑钢板固定，重新连接骨干与干骺端，早期功能锻炼，晚负重。,.,Openreductionandinternalfixationprinciples:(1)restorationoffibularlengthandinternalfixation;(2)achieveanatomicalreduction,reconstructionofdistaltibialarticularsurface(criticalfractureblock,Chaputnoduleetc.);(3)bonegraftofmetaphysealbonedefect(supportingthejointsurface,fillingthevacancy,stimulationofosteogenesis,acceleratefracturehealing);(4)thetibialmedialbuttressplatefixation,reconnectthebackboneandthemetaphysis,earlyfunctionalexercise,lateweightbearing.,.,治疗中的常见问题及并发症的防治：Pil