Pilon骨折ppt课件

1、Pilon骨折,1,学习交流PPT,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。,2,学习交流PPT,Definition：Pilon fracture refers to distal tibia fractures which involve tibia-astragalus articular surface. Pilon fracture havent got clear definiti

2、on yet, it usually refers to third distal tibia fractures spread from the joint. The distal tibial articular surface always serious shattered, bone defect and remote cancellous bone compression. It usually Associated with the lower part of fibula fractures (about 75% 85%) and serious soft tissue inj

3、ury.,3,学习交流PPT,名称来源：1911年首先由法国放射学家Destotti提出“tibial pilon”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“tibial platfond”，因此pilon骨折又称为platfond 骨折。,4,学习交流PPT,Definition origin:In 1911, the French radiologist Destotti firstly put forward the word -tibial pilon“. He described the shape of distal

4、 tibia as the pharmacists pestle (pilon). The distal tibial articular surface is also looks like ceiling;In 1950,bonin called it “tibial platfond”,so pilon fracture can be called Platfond fracture.,5,学习交流PPT,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

5、,受伤时踝关节的位置与骨折类型密切相关.,6,学习交流PPT,Injure mechanism:Tibial Pilon fractures occur most often in the fall, crash arrest, skiing or stumbling before the fall. Axial tibial violence or torsion violence of lower extremity are the main reason for distal tibial articular surface fractures. Two different mechan

6、isms of injury leading to different prognosis of Pilon fracture. The position of ankle joint when it hurts and the type of fracture are closely related.,7,学习交流PPT,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,8,学习交流PPT,Fracture c

7、haracteristic:It is a highly unstable fracture, and have severe articular cartilage damage. Treatment is difficult, with many complications, high disability rate, and it is one of the most challenging orthopaedic problems.,9,学习交流PPT,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

8、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。,10,学习交流PPT,Fracture classify: The main purpose of fracture classification is to guide treatment and prompt prognosis. In 1969 Ruedi and Augower divided Pilon fracture into 3 types according to the articular surface and metaphyseal displacement and crushing degree,

9、the meaning of this type lies in emphasizing the articular surface damage.,11,学习交流PPT,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。,12,学习交流PPT,The Ruedi-Allgower classification system: Type one:The articular surface fractures of distal tibia, a little displac

10、ement; Type two:The obvious articular surface shift and crush lesser degree; Type three:Articular surface crushing shift and the degree is serious. This type of commonly used clinical.,13,学习交流PPT,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）。,

11、14,学习交流PPT,Diagnosis:According to the medical history,symptoms, signs, combined with X, CT imagings, diagnosis is not difficult, pay attention to vascular, nerve, soft tissue injury, The inside of tibial, anterior open and potential open injury are common, carefully check the body. Pay attention not

12、 to miss the other part injury of the body (spinal fractures, upper fibula fracture etc).,15,学习交流PPT,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。,16,学习交流PPT,Treatment,(1) Non operation treatment: Adapted to the type I fractures without displacement, poor general condition wh

13、ich can not tolerate operation, as well as the treatment for the deferred operation. Mainly with manipulative reduction and plaster external fixation, calcaneal traction, closed pinning fixation,etc.,17,学习交流PPT,（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。,18,学习交流PPT,O

14、peration treatment: Operation indications: Tpre II, type III open fractures, fracture was obviously displaced or impacted, defect, accompanied by the nerve and vascular injury, the axial malalignment, articular surface fracture displacement is greater than 2mm, these all should be actively treated w

15、ith surgical operation.,19,学习交流PPT,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。,20,学习交流PPT,Operation principle: Low energy damage of Pilon fractures treated with open reduction a

16、nd internal fixation of positive ( ORIF ); high energy injury, take limited internal fixation and external fixation combined treatment. Currently advocated“ biology” principle: emphasizing meticulous soft tissue exposure, fracture block finite strip, indirect reduction, do early exercise after stabl

17、e fixation and late weight bearing,etc. Treatment goals can be summarized as “ 3P”, the protection of bone and soft tissue viability (preserve ), anatomical reduction of the articular surface (perform), provide fixations which can satisfy early motion of the ankle joint (provide).,21,学习交流PPT,手术时机：1、

18、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,22,学习交流PPT,Operation time: Patient of ope

19、n fractures to see a doctor early or turn up compartment syndrome, urgent operation treatment is necessary. For the serious pollution ( first debridement ), treatment time of late, severe soft tissue swelling, poor conditions of open fracture of calcaneus traction that go ahead of the rest, plaster

20、support, or over articular external fixator for treatment of temporary fixed, after swelling, blisters healed , do the secondary period of treatment. For a closed fracture of the operation opportunity, at present still exists controversy, I agree with that, in addition to poor conditions in the clos

21、ed fractures should do delayed operation, generally most fracture should do urgent surgry in 8-10 hours after injury when the swelling of a limb is not serious and no blister formation.This facilitates fracture reset. Higher tension and skin defect wound, may be left for secondary treatment.,23,学习交流

22、PPT,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) 。,24,学习交流PPT,Operation method: Type I: sometimes in order to avoid non operation treatment of possible displacement of fracture and shorten the time of external fixation, we choose limited open simple intern

23、al fixation combined with external fixation of plaster. After closed reduction and percutaneous hollow screw fixation, minimally invasive percutaneous plate osteosynthesis ( MIPPO technology );,25,学习交流PPT,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。,26,学习交流PPT,Type II: The

24、articular surface displaced, but not crushed and compressed, limited open reduction and internal fixation is appropriate. In recent years ,someone have advocated the arthroscopy combined with circular external fixation ;Arthroscopic assisted reduction and percutaneous screw fixation have also been u

25、sed .,27,学习交流PPT,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。,28,学习交流PPT,Type III: Closed highly unstable fractures, comminu

26、ted articular surface, choose classic open reduction with internal fixation and bone graft. Severe comminution have no anatomical reduction potential of high energy injury, massive bone defects, severe soft tissue injury, open fracture of the Gustilo II, type III were treated with limited internal f

27、ixation combined with external fixation is a good choice. Somebody claims reconstruction methods of fixation by stages, fix fibula firstly , at the same time using external fixation to maintain limb length and line of force, after 10-21d intermediate period, so that the soft tissue conditions can be

28、 fully improved to reduce postoperative soft tissue complications; then , the standard open reduction and internal fixation are used in the distal tibial articular surface.,29,学习交流PPT,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

29、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。,30,学习交流PPT,Arthrodesis and ankle joint replacement: Because not all of Pilon fracture patients can achieve complete anatomic reduction, even can achieve anatomic reduction, due to articular subchondral bone necrosis and collapse after fracture,it is inevitable t

30、hat the occurrence of traumatic osteoarthritis. Thus the arthrodesis and replacement of the ankle joint timing, should be based on the specific circumstances of the case. Generally after injury in 1-2 years according to the symptoms, signs, X ray performance and patients require fusion and replaceme

31、nt surgery.,31,学习交流PPT,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。,32,学习交流PPT,In conclusion, from the literature reports about Pilon clinical study on treatment of view, establish reasonable

32、and perfect preoperative planning, limited internal fixation combined with external fixation in the treatment of soft tissue injury and according to the staging of treatment, have reduced the soft tissue damage which leads to the complication rate, and obvious advantages have been proved. At the sam

33、e time, during the treatment of ankle joint and early functional exercise, avoid prolonged external fixation, can minimize the pin tract infection, joint stiffness and other complications.,33,学习交流PPT,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

34、）; （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。,34,学习交流PPT,Open reduction and internal fixation principles: ( 1) restoration of fibular length and internal fixation; ( 2) achieve anatomical reduction, reconstruction of distal tibial articular surface ( critical fracture block, Chaput nodule etc.); ( 3) bone

35、 graft of metaphyseal bone defect ( supporting the joint surface, filling the vacancy, stimulation of osteogenesis, accelerate fracture healing ); ( 4) the tibial medial buttress plate fixation, reconnect the backbone and the metaphysis, early functional exercise, late weight bearing.,35,学习交流PPT,治疗中的常见问题及并发症的防治： Pilon骨折，尤其是高能量损伤的Pilon骨折，并发症的