Pilon----骨折.ppt

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。lDefinition：Pilon fracture refers to distal tibia fractures which involve tibia-astragalus articular surface.Pilon fracture havent got clear definition 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 injury.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。lDefinition origin:In 1911,the French radiologist Destotti firstly put forward the word-tibial pilon“.He described the shape of distal 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.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.lInjure 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 mechanisms 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.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lFracture characteristic: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.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。lFracture 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,the meaning of this type lies in emphasizing the articular surface damage.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。The Ruedi-Allgower classification system:lType one:The articular surface fractures of distal tibia,a little displacement;lType two:The obvious articular surface shift and crush lesser degree;lType three:Articular surface crushing shift and the degree is serious.This type of commonly used clinical.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）。lDiagnosis: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 to miss the other part injury of the body(spinal fractures,upper fibula fracture etc).治疗l（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。Treatmentl(1)Non operation treatment:Adapted to the type I fractures without displacement,poor general condition which 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.（2）手术治疗：l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。lOperation treatment:lOperation 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 with surgical operation.l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。lOperation principle:Low energy damage of Pilon fractures treated with open reduction and 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 stable 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).l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lOperation time:Patient of open 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 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 closed 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.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)。lOperation method:lType 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 internal fixation combined with external fixation of plaster.After closed reduction and percutaneous hollow screw fixation,minimally invasive percutaneous plate osteosynthesis(MIPPO technology);l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。lType II:The 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 used.l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。l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。lType III:Closed highly unstable fractures,comminuted 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 fixation 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 fully improved to reduce postoperative soft tissue complications;then,the standard open reduction and internal fixation are used in the distal tibial articular surface.l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。lArthrodesis 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 that 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 replacement surgery.l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。lIn conclusion,from the literature reports about Pilon clinical study on treatment of view,establish reasonable 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 same 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.l切开复位内固定原则：l（1）恢复腓骨长度并做内固定;l（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）;l（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）;l（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。lOpen reduction and internal fixation principles:l(1)restoration of fibular length and internal fixation;l(2)achieve anatomical reduction,reconstruction of distal tibial articular surface(critical fracture block,Chaput nodule etc.);l(3)bone graft of metaphyseal bone defect(supporting the joint surface,filling the vacancy,stimulation of osteogenesis,accelerate fracture healing);l(4)the tibial medial buttress plate fixation,reconnect the backbone and the metaphysis,early functional exercise,late weight bearing.l治疗中的常见问题及并发症的防治：lPilon骨折，尤其是高能量损伤的Pilon骨折，并发症的发生率很高，处理好并发症的问题可以说是治疗Pilon骨折成败的关键。注意预防皮肤坏死、感染、创伤性关节炎、关节僵硬、畸形愈合、骨不愈合、延迟愈合。有报道用带关节的外固定架治疗高能量损伤的pilon骨折疗效满意，避免了关节僵硬。中西医结合防治并发症。lCommon problems in the treatment and prevention of complications:lPilon fracture,especially high energy injury Pilon fracture,have high incidence of complications,the treatment about complication problems can be said to be critical to the success of the treatment of Pilon fracture.Pay attention to the prevention of skin necrosis,infection,traumatic arthritis,joint stiffness,deformity,bone nonunion,delayed healing.There have been reports with articulated external fixator in the treatment of high energy injury Pilon fracture got curative effect satisfaction,it have prevented joint stiffness.Integrated traditional Chinese and Western medicine in the prevention and treatment of complications is a good choose.病案病案1:1:患者患者 xxxx，男，男，5252岁，岁，2 2小时前在工地干活时从高约小时前在工地干活时从高约3 3米处跌下致伤。查体：米处跌下致伤。查体：右胫骨远端及踝关节肿胀畸形，右内踝上方可见一右胫骨远端及踝关节肿胀畸形，右内踝上方可见一2*3cm2*3cm的伤口的伤口,可在皮下触及可在皮下触及骨折断端，有假关节活动，右足背动脉可扪及。身体其他部位未见异常，内科骨折断端，有假关节活动，右足背动脉可扪及。身体其他部位未见异常，内科情况稳定。情况稳定。病案病案2:2:患者患者 xxxx，男，男，4444岁，岁，1 1天前从高处跌下致伤。查体可见明显的天前从高处跌下致伤。查体可见明显的左侧左侧pilonpilon骨折体征（不赘述），闭合性，局部肿胀严重，多处张力骨折体征（不赘述），闭合性，局部肿胀严重，多处张力性水泡形成，左足背动脉可扪及。内科情况稳定。性水泡形成，左足背动脉可扪及。内科情况稳定。